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General NPI Number Information
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NPI Number | 1215174990
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Entity Type | Individual
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Provider Name | LISA ANN JACKSON CRNA
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Gender | Female
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Dates
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Enumeration Date | 01/16/2009
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Last Update Date | 01/16/2009
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Provider Practice Location Address
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Address Line | 2010 OLD W CHESTER PIKE SUITE 330
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City | HAVERTOWN
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State | PA
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Zip | 19083-2712
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Country | US
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Telephone | 610-789-8070
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Fax | 610-789-9937
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Provider Business Mailing Address
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Address Line | PO BOX 650782
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City | DALLAS
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State | TX
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Zip | 75265
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Country | US
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Telephone | 610-789-8070
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Fax | 610-789-9937
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | 081637
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License Number State | PA
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