Healthcare Provider Details

I. General information

NPI: 1437716529
Provider Name (Legal Business Name): JESSE TYLER LYONS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2019
Last Update Date: 09/27/2023
Certification Date: 09/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4530 SAINT JOHNS AVE STE 13
JACKSONVILLE FL
32210-1852
US

IV. Provider business mailing address

PO BOX 40767
JACKSONVILLE FL
32203-0767
US

V. Phone/Fax

Practice location:
  • Phone: 904-384-5222
  • Fax: 904-390-7461
Mailing address:
  • Phone: 904-376-3707
  • Fax: 904-391-5001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberME163619
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME163619
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: