Healthcare Provider Details

I. General information

NPI: 1437262375
Provider Name (Legal Business Name): JUDITH LYONS PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 E. WOODROW WILSON DRIVE VA-TRP (116A2)
JACKSON MS
39216-5199
US

IV. Provider business mailing address

PO BOX 55631
JACKSON MS
39296-5631
US

V. Phone/Fax

Practice location:
  • Phone: 601-364-1224
  • Fax: 601-368-3875
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number27 382
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: