Provider Demographics
NPI:1376853846
Name:JENKINS LEWIS, YVONNE DALE
Entity Type:Individual
Prefix:
First Name:YVONNE
Middle Name:DALE
Last Name:JENKINS LEWIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 MAGNOLIA ST
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32701-2063
Mailing Address - Country:US
Mailing Address - Phone:407-332-6378
Mailing Address - Fax:407-332-6378
Practice Address - Street 1:323 MAGNOLIA ST
Practice Address - Street 2:
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32701-2063
Practice Address - Country:US
Practice Address - Phone:407-332-6378
Practice Address - Fax:407-332-6378
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-18
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL678012196Medicaid
FL678012198Medicaid