Provider Demographics
NPI:1609630912
Name:LANE, JAYLA ROCHELLE
Entity Type:Individual
Prefix:
First Name:JAYLA
Middle Name:ROCHELLE
Last Name:LANE
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 1:1809 CLOVIS DR UNIT A
Mailing Address - Street 2:
Mailing Address - City:COPPERAS COVE
Mailing Address - State:TX
Mailing Address - Zip Code:76522-4283
Mailing Address - Country:US
Mailing Address - Phone:678-939-4257
Mailing Address - Fax:
Practice Address - Street 1:1524 LEANDER RD BLDG E
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78628-8801
Practice Address - Country:US
Practice Address - Phone:678-939-4257
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-07
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician