Basic Information
| Provider Information | |||||||||
| NPI: | 1295785913 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JAACKS | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8333 N DAVIS HWY FL 7 | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325146050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8509692038 | ||||||||
| FaxNumber: | 8509692037 | ||||||||
| Practice Location | |||||||||
| Address1: | 8333 N DAVIS HWY FL 7 | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325146050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8509692038 | ||||||||
| FaxNumber: | 8509692037 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 08/11/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 34977 | AZ | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | 156775 | FL | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 34977 | 01 | AZ | LICENSE | OTHER |