Basic Information
| Provider Information | |||||||||
| NPI: | 1679135701 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LYON | ||||||||
| FirstName: | JILL | ||||||||
| MiddleName: | LAVERNE | ||||||||
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| Credential: | CDPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12715 E MISSION AVE | ||||||||
| Address2: | |||||||||
| City: | SPOKANE VALLEY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992161027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5092325766 | ||||||||
| FaxNumber: | 5093215472 | ||||||||
| Practice Location | |||||||||
| Address1: | 1230 MONITOR ST | ||||||||
| Address2: | |||||||||
| City: | WENATCHEE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988013534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5092325766 | ||||||||
| FaxNumber: | 5093215472 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2019 | ||||||||
| LastUpdateDate: | 06/28/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CO60572125 | WA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 2077844 | 05 | WA | MEDICAID |