Provider Demographics
NPI:1750988754
Name:LISBERGER, JENNIFER M (MACCC/SLP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:LISBERGER
Suffix:
Gender:F
Credentials:MACCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 N 2ND ST UNIT 2C
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19106-4604
Mailing Address - Country:US
Mailing Address - Phone:610-316-9641
Mailing Address - Fax:
Practice Address - Street 1:130 N 2ND ST UNIT 2C
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19106-4604
Practice Address - Country:US
Practice Address - Phone:610-316-9641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-04
Last Update Date:2020-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL009455235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty