Healthcare Provider Details

I. General information

NPI: 1760562789
Provider Name (Legal Business Name): DEBORAH A LAKE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DEBORAH A JENNINGS

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

248 E CAPITOL ST 840 TRUST MARK BLDG
JACKSON MS
39201-2503
US

IV. Provider business mailing address

PO BOX 10414
LARGO FL
33773-0414
US

V. Phone/Fax

Practice location:
  • Phone: 800-632-6074
  • Fax: 866-341-7509
Mailing address:
  • Phone: 800-632-6074
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC0798
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: