Provider Demographics
NPI:1689903684
Name:MCBRIDE WASHINGTON, LISA J
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:J
Last Name:MCBRIDE WASHINGTON
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 1:3450 HIGHWAY 80 W
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39209-7201
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3450 HIGHWAY 80 W
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39209-7201
Practice Address - Country:US
Practice Address - Phone:601-321-2400
Practice Address - Fax:601-321-2476
Is Sole Proprietor?:No
Enumeration Date:2009-12-22
Last Update Date:2009-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST0327106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist