Provider Demographics
NPI:1619582640
Name:JACOBSEN, LISHA KERR
Entity Type:Individual
Prefix:
First Name:LISHA
Middle Name:KERR
Last Name:JACOBSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7936 WRENWOOD DRIVE
Mailing Address - Street 2:BLDG # A
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809
Mailing Address - Country:US
Mailing Address - Phone:225-910-2366
Mailing Address - Fax:
Practice Address - Street 1:7936 WRENWOOD DRIVE
Practice Address - Street 2:BLDG # A
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809
Practice Address - Country:US
Practice Address - Phone:225-910-2366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-15
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA8206101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty