MEDICARE: MS. LISA DONZE JACOB LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	7530	LA

General Provider Information

NPI Number	:	1629250261
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LISA DONZE JACOB LCSW

Provider Business Mailing Address
First Line	:	129 REIHER RD
Second Line	:
City	:	MANDEVILLE
State	:	LA
Zip	:	70471-7262
Country	:	US
Telephone Number	:	985-373-4418
Fax Number	:	985-727-7016

Provider Business Practice Location Address
First Line	:	1445 W CAUSEWAY APPROACH
Second Line	:
City	:	MANDEVILLE
State	:	LA
Zip	:	70471-3045
Country	:	US
Telephone Number	:	985-727-7993
Fax Number	:	985-727-7016

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/05/2007
Last Update Date	:	02/18/2013

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