Provider Demographics
NPI:1831965664
Name:JACKSON, LISA M
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:JACKSON
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 1:35 BURNS VIEW CT
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-7752
Mailing Address - Country:US
Mailing Address - Phone:908-380-5884
Mailing Address - Fax:
Practice Address - Street 1:915 CHANDLER AVE
Practice Address - Street 2:
Practice Address - City:LINDEN
Practice Address - State:NJ
Practice Address - Zip Code:07036-2086
Practice Address - Country:US
Practice Address - Phone:908-380-5884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-04
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)