MEDICARE: MS. LISA R JACKERT M.A., M.T.-B.C.

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	225A00000X	Music Therapist	CERT # 03815

General Provider Information

NPI Number	:	1679619381
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LISA R JACKERT M.A., M.T.-B.C.

Provider Business Mailing Address
First Line	:	PO BOX 3136
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90803-0136
Country	:	US
Telephone Number	:	562-716-0076
Fax Number	:

Provider Business Practice Location Address
First Line	:	301 ARGONNE AVE
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90814-3110
Country	:	US
Telephone Number	:	562-716-0076
Fax Number	:

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

Provider Enumeration Date	:	01/29/2007
Last Update Date	:	07/08/2007

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