MEDICARE: DR. JENNIFER MARIE LYON D.O.

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	207QS0010X	Sports Medicine (Family Medicine) Physician	5101016018	MI
2	207Q00000X	Family Medicine Physician	5101016018	MI

General Provider Information

NPI Number	:	1528283199
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JENNIFER MARIE LYON D.O.

Provider Business Mailing Address
First Line	:	647 E EIGHTH ST
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49686-2630
Country	:	US
Telephone Number	:	231-922-0400
Fax Number	:	231-922-3063

Provider Business Practice Location Address
First Line	:	647 E EIGHTH ST
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49686-2630
Country	:	US
Telephone Number	:	231-900-0400
Fax Number	:	855-586-8399

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

Provider Enumeration Date	:	04/17/2007
Last Update Date	:	02/15/2024

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