Provider Demographics
NPI:1174118921
Name:PETTAWAY, JALA
Entity type:Individual
Prefix:
First Name:JALA
Middle Name:
Last Name:PETTAWAY
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 1:900 W SOUTH BOUNDARY ST BLDG 6
Mailing Address - Street 2:
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-5235
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:900 W SOUTH BOUNDARY ST
Practice Address - Street 2:
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-5230
Practice Address - Country:US
Practice Address - Phone:419-419-6211
Practice Address - Fax:419-419-6231
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-03
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2910854Medicaid