Healthcare Provider Details

I. General information

NPI: 1790773737
Provider Name (Legal Business Name): LISA J SIMMONS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA M JACKSON

II. Dates (important events)

Enumeration Date: 10/13/2005
Last Update Date: 08/19/2025
Certification Date: 08/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4501 EMPIRE CT
FREDERICKSBURG VA
22408-1949
US

IV. Provider business mailing address

4501 EMPIRE CT
FREDERICKSBURG VA
22408-1949
US

V. Phone/Fax

Practice location:
  • Phone: 540-371-0079
  • Fax: 540-656-2769
Mailing address:
  • Phone: 540-371-0079
  • Fax: 540-656-2769

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number33840
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: