MEDICARE: JENNIFER M LISBERGER MACCC/SLP

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	235Z00000X	Speech-Language Pathologist	SL009455	PA

General Provider Information

NPI Number	:	1750988754
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER M LISBERGER MACCC/SLP

Provider Business Mailing Address
First Line	:	130 N 2ND ST UNIT 2C
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19106-4604
Country	:	US
Telephone Number	:	610-316-9641
Fax Number	:

Provider Business Practice Location Address
First Line	:	130 N 2ND ST UNIT 2C
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19106-4604
Country	:	US
Telephone Number	:	610-316-9641
Fax Number	:

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

Provider Enumeration Date	:	10/04/2020
Last Update Date	:	10/04/2020

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