Provider Demographics
NPI:1194254441
Name:LYON, JACOB (DO)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:
Last Name:LYON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1448 10TH AVE STE 304
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-3579
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:800 20TH ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25703-1850
Practice Address - Country:US
Practice Address - Phone:304-696-8701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-09
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV3601207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine