Provider Demographics
NPI:1043092430
Name:EVANS, JAYLAH (LPCA)
Entity Type:Individual
Prefix:
First Name:JAYLAH
Middle Name:
Last Name:EVANS
Suffix:
Gender:F
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 HOMESIDE AVE
Mailing Address - Street 2:
Mailing Address - City:WEST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06516-2413
Mailing Address - Country:US
Mailing Address - Phone:203-800-0647
Mailing Address - Fax:
Practice Address - Street 1:211 HOMESIDE AVE
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516-2413
Practice Address - Country:US
Practice Address - Phone:203-800-0647
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-19
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT6440101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional