Provider Demographics
NPI:1689031957
Name:LEWIS, JACQUELINE AMANDA (PTA)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:AMANDA
Last Name:LEWIS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 WAVERLY CT
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40206-2040
Mailing Address - Country:US
Mailing Address - Phone:502-418-2978
Mailing Address - Fax:502-238-5202
Practice Address - Street 1:1705 STEVENS AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205-1044
Practice Address - Country:US
Practice Address - Phone:502-451-7330
Practice Address - Fax:502-238-5240
Is Sole Proprietor?:No
Enumeration Date:2016-01-18
Last Update Date:2016-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA01882225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant