Healthcare Provider Details

I. General information

NPI: 1194254441
Provider Name (Legal Business Name): JACOB LYON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2017
Last Update Date: 11/24/2021
Certification Date: 11/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 20TH ST
HUNTINGTON WV
25703-1850
US

IV. Provider business mailing address

1448 10TH AVE STE 304
HUNTINGTON WV
25701-3579
US

V. Phone/Fax

Practice location:
  • Phone: 304-696-8701
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number3601
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: