Provider Demographics
NPI:1346574761
Name:JEPSON, LISA RENEE (PHD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:RENEE
Last Name:JEPSON
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 1:23 BROOK PL
Mailing Address - Street 2:
Mailing Address - City:EAST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11730-1001
Mailing Address - Country:US
Mailing Address - Phone:631-581-3081
Mailing Address - Fax:631-581-3081
Practice Address - Street 1:23 BROOK PL
Practice Address - Street 2:
Practice Address - City:EAST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11730-1001
Practice Address - Country:US
Practice Address - Phone:631-581-3081
Practice Address - Fax:631-581-3081
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-01
Last Update Date:2009-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013756-1103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist