Provider Demographics
NPI:1720342983
Name:LALA, JESSICA LYN (MSW, LCSW)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYN
Last Name:LALA
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56218 PARKWAY AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46516-9326
Mailing Address - Country:US
Mailing Address - Phone:574-293-0005
Mailing Address - Fax:574-293-0019
Practice Address - Street 1:56218 PARKWAY AVE
Practice Address - Street 2:SUITE B
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46516-9326
Practice Address - Country:US
Practice Address - Phone:574-293-0005
Practice Address - Fax:574-293-0019
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-02
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99052119A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical