Provider Demographics
NPI:1710359963
Name:LEWIS, JESSICA RAQUEL (PTA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:RAQUEL
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 1:1666 CARLYLE DR APT H
Mailing Address - Street 2:
Mailing Address - City:CROFTON
Mailing Address - State:MD
Mailing Address - Zip Code:21114-1428
Mailing Address - Country:US
Mailing Address - Phone:443-254-2089
Mailing Address - Fax:
Practice Address - Street 1:1666 CARLYLE DR APT H
Practice Address - Street 2:
Practice Address - City:CROFTON
Practice Address - State:MD
Practice Address - Zip Code:21114-1428
Practice Address - Country:US
Practice Address - Phone:443-254-2089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-28
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA4325225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant