Provider Demographics
NPI:1457120545
Name:LILLY, JEANNE MARIAH (PHD)
Entity Type:Individual
Prefix:DR
First Name:JEANNE
Middle Name:MARIAH
Last Name:LILLY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:785 OHIO AVE STE 3E
Mailing Address - Street 2:
Mailing Address - City:CLARKSDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38614-6215
Mailing Address - Country:US
Mailing Address - Phone:662-351-0702
Mailing Address - Fax:
Practice Address - Street 1:785 OHIO AVE STE 3E
Practice Address - Street 2:
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614-6215
Practice Address - Country:US
Practice Address - Phone:662-351-0702
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-29
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS621115103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist