Provider Demographics
NPI:1710353537
Name:LEWIS, JESSICA MARIE (MS, BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:LEWIS
Suffix:
Gender:F
Credentials:MS, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 S WESTNEDGE AVE
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49008-3208
Mailing Address - Country:US
Mailing Address - Phone:692-459-7821
Mailing Address - Fax:
Practice Address - Street 1:4200 S WESTNEDGE AVE
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49008-3208
Practice Address - Country:US
Practice Address - Phone:269-459-7821
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-16
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-17-26151103K00000X
MI7401000643103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst