Healthcare Provider Details

I. General information

NPI: 1720342983
Provider Name (Legal Business Name): JESSICA LYN LALA MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2012
Last Update Date: 10/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

56218 PARKWAY AVE SUITE B
ELKHART IN
46516-9326
US

IV. Provider business mailing address

56218 PARKWAY AVE SUITE B
ELKHART IN
46516-9326
US

V. Phone/Fax

Practice location:
  • Phone: 574-293-0005
  • Fax: 574-293-0019
Mailing address:
  • Phone: 574-293-0005
  • Fax: 574-293-0019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number99052119A
License Number StateIN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: