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General NPI Number Information
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NPI Number | 1760302061
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Entity Type | Individual
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Provider Name | JATEZIAH LYERISA LIVELY
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Gender | Female
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Dates
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Enumeration Date | 07/16/2026
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Last Update Date | 07/17/2026
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Provider Practice Location Address
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Address Line | 914 LILY CREEK RD
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City | LOUISVILLE
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State | KY
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Zip | 40243-2815
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Country | US
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Telephone | 502-291-4415
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Fax |
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Provider Business Mailing Address
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Address Line | 4917 CANE RUN RD
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City | LOUISVILLE
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State | KY
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Zip | 40216-1156
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Country | US
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Telephone | 502-291-4415
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 295156
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License Number State | KY
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