Provider Demographics
NPI:1992900336
Name:LAKE, JIMMA LANELLE (LPTA)
Entity type:Individual
Prefix:MRS
First Name:JIMMA
Middle Name:LANELLE
Last Name:LAKE
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
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Mailing Address - Street 1:PO BOX 81
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:TX
Mailing Address - Zip Code:76681-0081
Mailing Address - Country:US
Mailing Address - Phone:903-362-4012
Mailing Address - Fax:903-362-4012
Practice Address - Street 1:112 VINTAGE DR
Practice Address - Street 2:
Practice Address - City:WAXAHACHIE
Practice Address - State:TX
Practice Address - Zip Code:75165-6510
Practice Address - Country:US
Practice Address - Phone:214-632-9075
Practice Address - Fax:972-923-0493
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX2012555225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant