Provider Demographics
NPI:1154612620
Name:HYSON, JEFFREY DIETZ (LSW)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:DIETZ
Last Name:HYSON
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 BRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:SUNBURY
Mailing Address - State:PA
Mailing Address - Zip Code:17801-1006
Mailing Address - Country:US
Mailing Address - Phone:570-286-4982
Mailing Address - Fax:
Practice Address - Street 1:218 BRIDGE AVE
Practice Address - Street 2:
Practice Address - City:SUNBURY
Practice Address - State:PA
Practice Address - Zip Code:17801-1006
Practice Address - Country:US
Practice Address - Phone:570-286-4982
Practice Address - Fax:570-286-4984
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-02
Last Update Date:2011-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA125596104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker