Provider Demographics
NPI:1689958431
Name:JEZIORSKI, LISA
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:JEZIORSKI
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 1:229 VALLEYOAK CT
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63021-6550
Mailing Address - Country:US
Mailing Address - Phone:636-222-1474
Mailing Address - Fax:
Practice Address - Street 1:229 VALLEYOAK CT
Practice Address - Street 2:
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63021-6550
Practice Address - Country:US
Practice Address - Phone:636-222-1474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-28
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008031584235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist