Provider Demographics
NPI:1689813040
Name:JACOBSON, LISA (PHD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:JACOBSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1750 E FAIRMOUNT AVE
Mailing Address - Street 2:DEPARTMENT OF NEUROPSYCHOLOGY
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21231-1534
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1750 E FAIRMOUNT AVE
Practice Address - Street 2:DEPARTMENT OF NEUROPSYCHOLOGY
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21231-1534
Practice Address - Country:US
Practice Address - Phone:443-923-4431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-09
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MD04872103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program