Provider Demographics
NPI:1326614876
Name:LEWIS, JACKWLYN M (LADC)
Entity Type:Individual
Prefix:
First Name:JACKWLYN
Middle Name:M
Last Name:LEWIS
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 GOLD STRIKE DR APT 1
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:NE
Mailing Address - Zip Code:68701-2956
Mailing Address - Country:US
Mailing Address - Phone:660-888-3410
Mailing Address - Fax:
Practice Address - Street 1:200 N 34TH ST
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:NE
Practice Address - Zip Code:68701-3197
Practice Address - Country:US
Practice Address - Phone:402-371-3044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-03
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor