Provider Demographics
NPI:1629853940
Name:LEWIS, JACOB (LADC-1)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:LEWIS
Suffix:
Gender:M
Credentials:LADC-1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 KEENE ST
Mailing Address - Street 2:
Mailing Address - City:STONEHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02180-1173
Mailing Address - Country:US
Mailing Address - Phone:781-223-6896
Mailing Address - Fax:
Practice Address - Street 1:26 KEENE ST
Practice Address - Street 2:
Practice Address - City:STONEHAM
Practice Address - State:MA
Practice Address - Zip Code:02180-1173
Practice Address - Country:US
Practice Address - Phone:781-223-6896
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-25
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA23155101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)