MEDICARE: LISA JACKSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2355S0801X	Speech-Language Assistant	3776	LA

General Provider Information

NPI Number	:	1417713082
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA JACKSON

Provider Business Mailing Address
First Line	:	1810 LEONIDAS ST
Second Line	:
City	:	NEW ORLEANS
State	:	LA
Zip	:	70118-2112
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1810 LEONIDAS ST
Second Line	:
City	:	NEW ORLEANS
State	:	LA
Zip	:	70118-2112
Country	:	US
Telephone Number	:	504-657-7274
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/22/2024
Last Update Date	:	02/22/2024

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Directions to “ LISA JACKSON ” Practice Location

Language	Start Address	Practice Location

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