Provider Demographics
NPI:1316071749
Name:JACKSON, LISA ANN (PHD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:ANN
Last Name:JACKSON
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 1:332 DAN TROY DR
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-3514
Mailing Address - Country:US
Mailing Address - Phone:716-839-4658
Mailing Address - Fax:
Practice Address - Street 1:4955 N BAILEY AVE
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14226-1206
Practice Address - Country:US
Practice Address - Phone:716-833-0292
Practice Address - Fax:716-833-0215
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011968103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01474937Medicaid