Provider Demographics
NPI:1750763918
Name:JURKIEWICZ, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:JURKIEWICZ
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 1:3776 PATUXENT RIVER RD
Mailing Address - Street 2:
Mailing Address - City:DAVIDSONVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21035-2419
Mailing Address - Country:US
Mailing Address - Phone:443-808-1218
Mailing Address - Fax:
Practice Address - Street 1:1119 STATE ROUTE 3 N STE 201
Practice Address - Street 2:
Practice Address - City:GAMBRILLS
Practice Address - State:MD
Practice Address - Zip Code:21054-1788
Practice Address - Country:US
Practice Address - Phone:443-808-1218
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-24
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202007908235Z00000X
DCSLP001045235Z00000X
MD09365235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist