Provider Demographics
NPI:1710301817
Name:LEWIS, JENNIFER TICKNER (MA-CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:TICKNER
Last Name:LEWIS
Suffix:
Gender:F
Credentials:MA-CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7244 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-2014
Mailing Address - Country:US
Mailing Address - Phone:614-501-1020
Mailing Address - Fax:
Practice Address - Street 1:7244 E MAIN ST
Practice Address - Street 2:
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068-2014
Practice Address - Country:US
Practice Address - Phone:614-501-1020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-10
Last Update Date:2018-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP.9763235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH235Z00000XMedicaid