Provider Demographics
NPI:1568947521
Name:JACOBY, LISA (RDH)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:JACOBY
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 5TH ST NW
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33881-4672
Mailing Address - Country:US
Mailing Address - Phone:863-268-7850
Mailing Address - Fax:863-268-7899
Practice Address - Street 1:106 NW 9TH AVE
Practice Address - Street 2:
Practice Address - City:MULBERRY
Practice Address - State:FL
Practice Address - Zip Code:33860-2922
Practice Address - Country:US
Practice Address - Phone:863-425-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-26
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDH17486124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist