Provider Demographics
NPI:1902969363
Name:JAL PSYCHOLOGICAL SERVICES
Entity Type:Organization
Organization Name:JAL PSYCHOLOGICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:ALLISON
Authorized Official - Last Name:LANUM
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:478-474-4073
Mailing Address - Street 1:3626 VINEVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31204-1853
Mailing Address - Country:US
Mailing Address - Phone:478-474-4073
Mailing Address - Fax:478-474-4074
Practice Address - Street 1:3626 VINEVILLE AVE
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31204-1853
Practice Address - Country:US
Practice Address - Phone:478-474-4073
Practice Address - Fax:478-474-4074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY002796103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty