Tyler Stacy, LPC

Primary specialty

Professional CounselorTaxonomy code 101YP2500X

License

2366 Issued in MS

Practice address

4500 I 55 N Ste 208
Jackson, MS 39211-5931

Phone

(601) 405-7440

NPI assigned

Feb 17, 2017

Last updated

Mar 19, 2019By the provider in NPPES

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Opted out of Medicare

Yes, effective Jul 3, 2024 through Jul 3, 2028

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1487289600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1552953600000",
    "number": "1376082719",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4500 I 55 N STE 208",
            "city": "JACKSON",
            "state": "MS",
            "postal_code": "392115931",
            "telephone_number": "601-405-7440"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4500 I 55 N STE 208",
            "city": "JACKSON",
            "state": "MS",
            "postal_code": "392115931",
            "telephone_number": "601-405-7440"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "622 Riverside Dr",
            "address_purpose": "LOCATION",
            "city": "Monroe",
            "state": "LA",
            "postal_code": "712016211",
            "country_code": "US",
            "telephone_number": "601-317-4517",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "STACY",
        "first_name": "TYLER",
        "credential": "LPC",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2017-02-17",
        "last_updated": "2019-03-19",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101Y00000X",
            "taxonomy_group": "",
            "desc": "Counselor",
            "state": "LA",
            "license": "6721",
            "primary": false
        },
        {
            "code": "101YP2500X",
            "taxonomy_group": "",
            "desc": "Counselor, Professional",
            "state": "MS",
            "license": "2366",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• St. Dominic-Jackson Memorial Hospital
• Mariah St.Clair
• Sta-Home Hospice
• Michael Bryan Stack
• Jason Dean Stacy, M.D.
• Staffing Innovations Inc.
• Beverly Fulgham Stafford, CRNA
• Abigail Kathleen Stallings, DO
• Brenda L Stallion-Pate, FNP
• Danielle Stamps, NCC

• Professional Counselor in Jackson, MS
• Providers in Jackson, MS by specialty
• Professional Counselor in Mississippi

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 19, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Opt Out Affidavits.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.