Provider Demographics
NPI:1497389647
Name:JAE, LORA
Entity Type:Individual
Prefix:
First Name:LORA
Middle Name:
Last Name:JAE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:
Other - Last Name:LARSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:225 FRONT ST STE 202
Mailing Address - Street 2:
Mailing Address - City:JUNEAU
Mailing Address - State:AK
Mailing Address - Zip Code:99801-1244
Mailing Address - Country:US
Mailing Address - Phone:218-576-2659
Mailing Address - Fax:
Practice Address - Street 1:225 FRONT ST STE 202
Practice Address - Street 2:
Practice Address - City:JUNEAU
Practice Address - State:AK
Practice Address - Zip Code:99801-1244
Practice Address - Country:US
Practice Address - Phone:218-576-2659
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-26
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)