Provider Demographics
NPI:1083373625
Name:JACKSON, LYRIC LEANNA
Entity Type:Individual
Prefix:
First Name:LYRIC
Middle Name:LEANNA
Last Name:JACKSON
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 1:4225 PENDLETON DR APT 2203
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-2684
Mailing Address - Country:US
Mailing Address - Phone:804-385-5551
Mailing Address - Fax:
Practice Address - Street 1:2900 E 29TH ST
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-2622
Practice Address - Country:US
Practice Address - Phone:979-776-8440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-10
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist