Provider Demographics
NPI:1619582640
Name:JACOBSEN, LISHA KERR
Entity type:Individual
Prefix:
First Name:LISHA
Middle Name:KERR
Last Name:JACOBSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 INDUSTRIAL DR STE 2183
Mailing Address - Street 2:
Mailing Address - City:WILDWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:34785-4707
Mailing Address - Country:US
Mailing Address - Phone:225-424-7622
Mailing Address - Fax:
Practice Address - Street 1:901 INDUSTRIAL DR STE 2183
Practice Address - Street 2:
Practice Address - City:WILDWOOD
Practice Address - State:FL
Practice Address - Zip Code:34785-4707
Practice Address - Country:US
Practice Address - Phone:225-424-7622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-15
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA8206101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty