Provider Demographics
NPI:1568748598
Name:JACKSON, LISA (MS, MFT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MS, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 FORWARD DR.
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53711
Mailing Address - Country:US
Mailing Address - Phone:608-268-6530
Mailing Address - Fax:608-709-1744
Practice Address - Street 1:815 FORWARD DR.
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53711
Practice Address - Country:US
Practice Address - Phone:608-268-6530
Practice Address - Fax:608-709-1744
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-21
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI249-228106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist