Provider Demographics
NPI:1982488821
Name:LYONS, JENNIE FAY (LCSW)
Entity type:Individual
Prefix:
First Name:JENNIE
Middle Name:FAY
Last Name:LYONS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:JENNIE
Other - Middle Name:FAY
Other - Last Name:KINCHELOE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2835 SW MAYO RD
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32024-0509
Mailing Address - Country:US
Mailing Address - Phone:386-961-3098
Mailing Address - Fax:
Practice Address - Street 1:6037 W US HIGHWAY 90
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-8196
Practice Address - Country:US
Practice Address - Phone:386-961-0155
Practice Address - Fax:386-961-0156
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-22
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW154431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical