Healthcare Provider Details

I. General information

NPI: 1376409201
Provider Name (Legal Business Name): JENNIFER LYASH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2026
Last Update Date: 01/05/2026
Certification Date: 01/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 BLYTHE MILL RD
WAXHAW NC
28173-0466
US

IV. Provider business mailing address

1647 LOGGERHEAD DR
LANCASTER SC
29720-0394
US

V. Phone/Fax

Practice location:
  • Phone: 984-212-0028
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: