Provider Demographics
NPI:1467101857
Name:LEWIS, JONATHAN RAY
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:RAY
Last Name:LEWIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3150 GARRISON RD APT 921
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:TX
Mailing Address - Zip Code:76210-1820
Mailing Address - Country:US
Mailing Address - Phone:843-901-7726
Mailing Address - Fax:
Practice Address - Street 1:6211 SOUTHWEST BLVD
Practice Address - Street 2:
Practice Address - City:BENBROOK
Practice Address - State:TX
Practice Address - Zip Code:76132-1080
Practice Address - Country:US
Practice Address - Phone:817-310-8792
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-22
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician