MEDICARE: MS. JACLYNN LIZAMA

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	126800000X	Dental Assistant

General Provider Information

NPI Number	:	1588507487
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JACLYNN LIZAMA

Provider Business Mailing Address
First Line	:	605 RANDOLPH RD
Second Line	:
City	:	LAWTON
State	:	OK
Zip	:	73503-4535
Country	:	US
Telephone Number	:	580-442-5925
Fax Number	:

Provider Business Practice Location Address
First Line	:	605 RANDOLPH RD
Second Line	:
City	:	LAWTON
State	:	OK
Zip	:	73503-4535
Country	:	US
Telephone Number	:	580-442-5925
Fax Number	:

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

Provider Enumeration Date	:	04/14/2026
Last Update Date	:	04/14/2026

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