Provider Demographics
NPI:1427734102
Name:JESSUP LYONS, SANDRA STACEY (MSW, LAC)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:STACEY
Last Name:JESSUP LYONS
Suffix:
Gender:F
Credentials:MSW, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 TALON WAY UNIT A
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718-9626
Mailing Address - Country:US
Mailing Address - Phone:406-599-4157
Mailing Address - Fax:
Practice Address - Street 1:2310 N 7TH AVE
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-2550
Practice Address - Country:US
Practice Address - Phone:406-586-5493
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-26
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT57706101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)