Provider Demographics
NPI:1841807245
Name:LISBERGER, JACLYN ISIS (MACCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:JACLYN
Middle Name:ISIS
Last Name:LISBERGER
Suffix:
Gender:F
Credentials:MACCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 NORTH 2ND STREET-#2E
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19106
Mailing Address - Country:US
Mailing Address - Phone:610-316-1532
Mailing Address - Fax:
Practice Address - Street 1:130 NORTH 2ND STREET-#2E
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19106
Practice Address - Country:US
Practice Address - Phone:610-316-1532
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-29
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL009109235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist