Healthcare Provider Details

I. General information

NPI: 1780967513
Provider Name (Legal Business Name): LISA SPENCER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2011
Last Update Date: 09/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

970 LAKELAND DR STE 40
JACKSON MS
39216-4640
US

IV. Provider business mailing address

PO BOX 23666
JACKSON MS
39225
US

V. Phone/Fax

Practice location:
  • Phone: 601-200-4850
  • Fax: 601-200-4838
Mailing address:
  • Phone: 601-200-4850
  • Fax: 601-200-4838

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberA0637
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: