Provider Demographics
NPI:1629250261
Name:JACOB, LISA DONZE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:DONZE
Last Name:JACOB
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:DONZE
Other - Last Name:ERICHSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:129 REIHER RD
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70471-7262
Mailing Address - Country:US
Mailing Address - Phone:985-373-4418
Mailing Address - Fax:985-727-7016
Practice Address - Street 1:1445 W CAUSEWAY APPROACH
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70471-3045
Practice Address - Country:US
Practice Address - Phone:985-727-7993
Practice Address - Fax:985-727-7016
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-05
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA75301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical