Provider Demographics
NPI:1750304275
Name:JACKSON-CHERRY, LISA RENE'
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:RENE'
Last Name:JACKSON-CHERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:RENE'
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:704 CHESTER RIVER DR
Mailing Address - Street 2:
Mailing Address - City:GRASONVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21638-1003
Mailing Address - Country:US
Mailing Address - Phone:410-827-4164
Mailing Address - Fax:
Practice Address - Street 1:1114 DIDINATO DR
Practice Address - Street 2:CHESTER REGIONAL MEDICAL CENTER
Practice Address - City:CHESTER
Practice Address - State:MD
Practice Address - Zip Code:21619
Practice Address - Country:US
Practice Address - Phone:410-490-0535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLCPC0403101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDOX94OtherBLUE CROSS BLUE SHIELD