Provider Demographics
NPI:1669830725
Name:LEW, JACK (RN)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:LEW
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 OCEAN VIEW AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-6313
Mailing Address - Country:US
Mailing Address - Phone:718-769-7998
Mailing Address - Fax:
Practice Address - Street 1:601 OCEAN VIEW AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-6313
Practice Address - Country:US
Practice Address - Phone:718-769-7998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-04
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY637228163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse