Healthcare Provider Details

I. General information

NPI: 1558956243
Provider Name (Legal Business Name): LISA JERRY PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2021
Last Update Date: 06/24/2025
Certification Date: 06/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 N MAIN ST
GLASSBORO NJ
08028-1605
US

IV. Provider business mailing address

707 N MAIN ST STE 1
GLASSBORO NJ
08028-1670
US

V. Phone/Fax

Practice location:
  • Phone: 856-307-9700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305214146
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT872756
License Number StateDC
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberCP044993T
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: