Provider Demographics
NPI:1679619381
Name:JACKERT, LISA R (MA, MT-BC)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:R
Last Name:JACKERT
Suffix:
Gender:F
Credentials:MA, MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3136
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90803-0136
Mailing Address - Country:US
Mailing Address - Phone:562-716-0076
Mailing Address - Fax:
Practice Address - Street 1:301 ARGONNE AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90814-3110
Practice Address - Country:US
Practice Address - Phone:562-716-0076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CERT # 03815225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist