Provider Demographics
NPI:1053822684
Name:LYONS, JACKIE DENISE (LCDC 3)
Entity Type:Individual
Prefix:MISS
First Name:JACKIE
Middle Name:DENISE
Last Name:LYONS
Suffix:
Gender:F
Credentials:LCDC 3
Other - Prefix:MISS
Other - First Name:JACQUELINE
Other - Middle Name:D
Other - Last Name:LYONS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCDC 3
Mailing Address - Street 1:2211 FULTON AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45206-2504
Mailing Address - Country:US
Mailing Address - Phone:513-961-4663
Mailing Address - Fax:513-961-4681
Practice Address - Street 1:2203 FULTON AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45206-2504
Practice Address - Country:US
Practice Address - Phone:513-961-4663
Practice Address - Fax:513-961-4681
Is Sole Proprietor?:No
Enumeration Date:2017-10-23
Last Update Date:2017-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH131083101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)