Provider Demographics
NPI:1083134449
Name:LEWIS, JESA LEE (LMT)
Entity Type:Individual
Prefix:
First Name:JESA
Middle Name:LEE
Last Name:LEWIS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:JESA
Other - Middle Name:LEE PESA
Other - Last Name:TIDWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:308 OLD STEESE HWY
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-3126
Mailing Address - Country:US
Mailing Address - Phone:907-451-7246
Mailing Address - Fax:
Practice Address - Street 1:308 OLD STEESE HWY
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-3126
Practice Address - Country:US
Practice Address - Phone:907-451-7246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist