Provider Demographics
NPI:1104958305
Name:JACOBS, LISA MARION (PHD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARION
Last Name:JACOBS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 WOODLAND AVE
Mailing Address - Street 2:
Mailing Address - City:SUMMIT
Mailing Address - State:NJ
Mailing Address - Zip Code:07901-2112
Mailing Address - Country:US
Mailing Address - Phone:908-598-0870
Mailing Address - Fax:908-522-6668
Practice Address - Street 1:55 WOODLAND AVE
Practice Address - Street 2:
Practice Address - City:SUMMIT
Practice Address - State:NJ
Practice Address - Zip Code:07901-2112
Practice Address - Country:US
Practice Address - Phone:908-598-0870
Practice Address - Fax:908-522-6668
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist