Provider Demographics
NPI:1578236584
Name:LEWIS, JAIDEN
Entity Type:Individual
Prefix:
First Name:JAIDEN
Middle Name:
Last Name: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 1:10846 JOHN GALT BLVD
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68137-2306
Mailing Address - Country:US
Mailing Address - Phone:402-325-1290
Mailing Address - Fax:
Practice Address - Street 1:10846 JOHN GALT BLVD
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68137-2306
Practice Address - Country:US
Practice Address - Phone:402-325-1290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-26
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NEP-1902101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)