Healthcare Provider Details

I. General information

NPI: 1174118921
Provider Name (Legal Business Name): JALA PETTAWAY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2021
Last Update Date: 03/28/2022
Certification Date: 03/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 W SOUTH BOUNDARY ST
PERRYSBURG OH
43551-5230
US

IV. Provider business mailing address

900 W SOUTH BOUNDARY ST BLDG 6
PERRYSBURG OH
43551-5235
US

V. Phone/Fax

Practice location:
  • Phone: 419-419-6211
  • Fax: 419-419-6231
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: