Provider Demographics
NPI:1952164865
Name:KIRK, LISA JACKSON
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:JACKSON
Last Name:KIRK
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 1:235 CIVIC CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70360-5937
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:235 CIVIC CENTER BLVD
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70360-5937
Practice Address - Country:US
Practice Address - Phone:985-900-1626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-02
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA0595095163WP0808X
LA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health