Individual
JAELIAH LANE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
6 EAGLE CTR STE 1, O FALLON, IL 62269-1945
(618) 206-8816
Mailing address
9902 W MAIN ST APT 10, BELLEVILLE, IL 62223-1420
(618) 691-4777
Taxonomy
Speciality
Code
Description
License number
State
106S00000X
Behavior Technician
Primary
—
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
L500-4319-7616
DRIVERS LICENSE
IL
Enumeration date
01/06/2021
Last updated
01/06/2021
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