Provider Demographics
NPI:1730902438
Name:LYON, JESSICA ANNE
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANNE
Last Name:LYON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26350 N DUSTIN RD
Mailing Address - Street 2:
Mailing Address - City:ACAMPO
Mailing Address - State:CA
Mailing Address - Zip Code:95220-9626
Mailing Address - Country:US
Mailing Address - Phone:209-200-5557
Mailing Address - Fax:
Practice Address - Street 1:1530 W KETTLEMAN LN STE A
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-8909
Practice Address - Country:US
Practice Address - Phone:209-263-7170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-02
Last Update Date:2024-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician