Provider Demographics
NPI:1164243077
Name:LAFAVE, JACQUELINE ANN
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ANN
Last Name:LAFAVE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9204 E 93RD AVE
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-8620
Mailing Address - Country:US
Mailing Address - Phone:708-296-3781
Mailing Address - Fax:
Practice Address - Street 1:41 WILLIAMS ST
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:IN
Practice Address - Zip Code:46320-1948
Practice Address - Country:US
Practice Address - Phone:219-933-2464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-23
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10068788103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool