MEDICARE: DR. JEANNE MARIAH LILLY PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	621115	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1457120545
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEANNE MARIAH LILLY PHD

Provider Business Mailing Address
First Line	:	785 OHIO AVE STE 3E
Second Line	:
City	:	CLARKSDALE
State	:	MS
Zip	:	38614-6215
Country	:	US
Telephone Number	:	662-351-0702
Fax Number	:	662-351-0703

Provider Business Practice Location Address
First Line	:	785 OHIO AVE STE 3E
Second Line	:
City	:	CLARKSDALE
State	:	MS
Zip	:	38614-6215
Country	:	US
Telephone Number	:	662-351-0702
Fax Number	:	662-351-0703

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/29/2023
Last Update Date	:	08/07/2024

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