Provider Demographics
NPI:1013632116
Name:MADDOX, LISA JEANNE
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:JEANNE
Last Name:MADDOX
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:PO BOX 748465
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-8465
Mailing Address - Country:US
Mailing Address - Phone:855-284-7483
Mailing Address - Fax:617-807-0958
Practice Address - Street 1:4243 SUNBEAM RD STE 1
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32257-8975
Practice Address - Country:US
Practice Address - Phone:855-284-7483
Practice Address - Fax:617-807-0958
Is Sole Proprietor?:No
Enumeration Date:2022-10-11
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL101YM0800X
FLMH22914101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health