Healthcare Provider Details

I. General information

NPI: 1144008046
Provider Name (Legal Business Name): JESSICA M LISK AG-ACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2023
Last Update Date: 06/26/2025
Certification Date: 06/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1204 W MAIN ST
CHARLOTTESVILLE VA
22903-2824
US

IV. Provider business mailing address

PO BOX 749112
ATLANTA GA
30374-9112
US

V. Phone/Fax

Practice location:
  • Phone: 434-924-9119
  • Fax:
Mailing address:
  • Phone: 434-295-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number0024188126
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number0024188126
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number0024188126
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: