Provider Demographics
NPI:1619296340
Name:LEWCHALERMWONG, JACQUELYN AMERA (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:AMERA
Last Name:LEWCHALERMWONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 645
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:VA
Mailing Address - Zip Code:24348-0645
Mailing Address - Country:US
Mailing Address - Phone:310-953-1919
Mailing Address - Fax:
Practice Address - Street 1:1117 APPLE VALLEY RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:TN
Practice Address - Zip Code:37115-2305
Practice Address - Country:US
Practice Address - Phone:310-953-1919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-20
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAMD-R-8813207Q00000X
CAA118019208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine