Healthcare Provider Details

I. General information

NPI: 1205422862
Provider Name (Legal Business Name): MYRA LOTT LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2020
Last Update Date: 09/26/2022
Certification Date: 03/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1991 LAKELAND DR STE E
JACKSON MS
39216-5000
US

IV. Provider business mailing address

45 LOTT CIR
SEMINARY MS
39479-4262
US

V. Phone/Fax

Practice location:
  • Phone: 601-613-1980
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2565
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: