Provider Demographics
NPI:1376027367
Name:LEWIS, JONATHAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:LEWIS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6425 NICOLLET AVE
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55423-1675
Mailing Address - Country:US
Mailing Address - Phone:612-861-1675
Mailing Address - Fax:
Practice Address - Street 1:6425 NICOLLET AVE
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55423-1675
Practice Address - Country:US
Practice Address - Phone:612-861-1675
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-17
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6274103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical