Provider Demographics
NPI:1124834858
Name:JACKSON, LISA D
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:D
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9134 PISCATAWAY RD UNIT 371
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MD
Mailing Address - Zip Code:20735-7615
Mailing Address - Country:US
Mailing Address - Phone:240-444-5976
Mailing Address - Fax:
Practice Address - Street 1:9134 PISCATAWAY RD UNIT 371
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MD
Practice Address - Zip Code:20735-7615
Practice Address - Country:US
Practice Address - Phone:240-444-5976
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-07
Last Update Date:2024-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program