Provider Demographics
NPI:1942706023
Name:LYLES, JESSICA MARIE
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:LYLES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:MARIE
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MARRIAGE
Mailing Address - Street 1:248 BIRDS EYE VW
Mailing Address - Street 2:
Mailing Address - City:BOILING SPRINGS
Mailing Address - State:SC
Mailing Address - Zip Code:29316-5358
Mailing Address - Country:US
Mailing Address - Phone:803-363-1954
Mailing Address - Fax:
Practice Address - Street 1:248 BIRDS EYE VW
Practice Address - Street 2:
Practice Address - City:BOILING SPRINGS
Practice Address - State:SC
Practice Address - Zip Code:29316-5358
Practice Address - Country:US
Practice Address - Phone:803-363-1954
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-05
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health