Provider Demographics
NPI:1720768401
Name:LAVALLE, JENNIFER LEE (CPSS)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEE
Last Name:LAVALLE
Suffix:
Gender:F
Credentials:CPSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:591 RIVER RD APT A
Mailing Address - Street 2:
Mailing Address - City:COLDWATER
Mailing Address - State:MI
Mailing Address - Zip Code:49036-9275
Mailing Address - Country:US
Mailing Address - Phone:517-677-7792
Mailing Address - Fax:
Practice Address - Street 1:200 VISTA DR
Practice Address - Street 2:
Practice Address - City:COLDWATER
Practice Address - State:MI
Practice Address - Zip Code:49036-1776
Practice Address - Country:US
Practice Address - Phone:517-278-8129
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-19
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist