Provider Demographics
NPI:1174111975
Name:LANE, JAELIAH
Entity type:Individual
Prefix:
First Name:JAELIAH
Middle Name:
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 1:9902 W MAIN ST APT 10
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223-1420
Mailing Address - Country:US
Mailing Address - Phone:618-691-4777
Mailing Address - Fax:
Practice Address - Street 1:6 EAGLE CTR STE 1
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1945
Practice Address - Country:US
Practice Address - Phone:618-206-8816
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-06
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL500-4319-7616OtherDRIVERS LICENSE