Provider Demographics
NPI:1962991588
Name:LAKE, JALISSA
Entity type:Individual
Prefix:
First Name:JALISSA
Middle Name:
Last Name:LAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7108 SOUTH KANNER HWY,
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997-7462
Mailing Address - Country:US
Mailing Address - Phone:866-610-0580
Mailing Address - Fax:
Practice Address - Street 1:4940 NORTHDALE BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33624-1075
Practice Address - Country:US
Practice Address - Phone:813-485-8444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-09
Last Update Date:2022-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician