Provider Demographics
NPI:1396389029
Name:JACKSON, LISA MICHELLE (PP, BS)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MICHELLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PP, BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6200 BRADLEY PARK DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-3078
Mailing Address - Country:US
Mailing Address - Phone:706-604-7640
Mailing Address - Fax:
Practice Address - Street 1:6200 BRADLEY PARK DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-3078
Practice Address - Country:US
Practice Address - Phone:706-604-7640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-06
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator