MEDICARE: LISA JACKSON

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	101Y00000X	Counselor

General Provider Information

NPI Number	:	1821859018
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA JACKSON

Provider Business Mailing Address
First Line	:	2931 BUCKNER LN
Second Line	:
City	:	SPRING HILL
State	:	TN
Zip	:	37174-8242
Country	:	US
Telephone Number	:	805-450-7270
Fax Number	:

Provider Business Practice Location Address
First Line	:	2931 BUCKNER LN
Second Line	:
City	:	SPRING HILL
State	:	TN
Zip	:	37174-8242
Country	:	US
Telephone Number	:	805-450-7270
Fax Number	:

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

Provider Enumeration Date	:	01/16/2024
Last Update Date	:	01/16/2024

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Directions to “ LISA JACKSON ” Practice Location

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