Healthcare Provider Details

I. General information

NPI: 1861312886
Provider Name (Legal Business Name): JAYA LALITHA MALLELA MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2026
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 CLARK HALL
COLUMBIA MO
65211-4423
US

IV. Provider business mailing address

2303 WHITEGATE DR APT 3A
COLUMBIA MO
65202-2330
US

V. Phone/Fax

Practice location:
  • Phone: 856-840-5058
  • Fax:
Mailing address:
  • Phone: 856-840-5058
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: