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NPI Code Detail

MEDICARE: JALISSA LAKE

MEDICARE: JALISSA LAKE
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1106S00000XBehavior Technician
2103K00000XBehavior Analyst

General Provider Information

NPI Number : 1962991588
Entity Type Code : Individual
Provider Name (Legal Business Name) : JALISSA LAKE
Provider Business Mailing Address
First Line : 4940 NORTHDALE BLVD
Second Line :
City : TAMPA
State : FL
Zip : 33624-1075
Country : US
Telephone Number : 813-485-8444
Fax Number :
Provider Business Practice Location Address
First Line : 4940 NORTHDALE BLVD
Second Line :
City : TAMPA
State : FL
Zip : 33624-1075
Country : US
Telephone Number : 813-485-8444
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/09/2018
Last Update Date : 08/07/2025

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Directions to “ JALISSA LAKE ” Practice Location

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These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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