Provider Demographics
NPI:1578991360
Name:LEWALLEN, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:LEWALLEN
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 1:1925 HAYES AVE
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44870-4737
Mailing Address - Country:US
Mailing Address - Phone:419-557-5177
Mailing Address - Fax:419-557-5179
Practice Address - Street 1:122 W CENTER ST
Practice Address - Street 2:
Practice Address - City:FOSTORIA
Practice Address - State:OH
Practice Address - Zip Code:44830-2201
Practice Address - Country:US
Practice Address - Phone:419-435-0204
Practice Address - Fax:419-436-9846
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-15
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.1200728101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor