Provider Demographics
NPI:1043425325
Name:LEWIS, JACOB (MA)
Entity Type:Individual
Prefix:MR
First Name:JACOB
Middle Name:
Last Name:LEWIS
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:809 NORTH 19TH STREET SELFREFIND
Mailing Address - Street 2:
Mailing Address - City:MIDDLESBORO
Mailing Address - State:KY
Mailing Address - Zip Code:40965
Mailing Address - Country:US
Mailing Address - Phone:865-585-6681
Mailing Address - Fax:
Practice Address - Street 1:809 NORTH 19TH STREET SELFREFIND
Practice Address - Street 2:
Practice Address - City:MIDDLESBORO
Practice Address - State:KY
Practice Address - Zip Code:40965-1845
Practice Address - Country:US
Practice Address - Phone:865-585-6681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health