Provider Demographics
NPI:1710500061
Name:LEWALLEN, JACOB DEWAYNE (DC)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:DEWAYNE
Last Name:LEWALLEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1351 TILDEN RD
Mailing Address - Street 2:
Mailing Address - City:GALENA
Mailing Address - State:MO
Mailing Address - Zip Code:65656-8633
Mailing Address - Country:US
Mailing Address - Phone:417-872-7728
Mailing Address - Fax:
Practice Address - Street 1:714 STATE HIGHWAY 248 STE 503
Practice Address - Street 2:
Practice Address - City:BRANSON
Practice Address - State:MO
Practice Address - Zip Code:65616-3761
Practice Address - Country:US
Practice Address - Phone:417-872-7728
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-21
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020012893111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor