Provider Demographics
NPI:1376138347
Name:JACKSON, LEWIS (PHD)
Entity Type:Individual
Prefix:
First Name:LEWIS
Middle Name:
Last Name:JACKSON
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 1:111 N HUBBARDS LN STE 1
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-3902
Mailing Address - Country:US
Mailing Address - Phone:859-475-2184
Mailing Address - Fax:
Practice Address - Street 1:111 N HUBBARDS LN STE 1
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-3902
Practice Address - Country:US
Practice Address - Phone:859-475-2184
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-02
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physician