Provider Demographics
NPI:1720410319
Name:LEWIS, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 N 93RD ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114-2697
Mailing Address - Country:US
Mailing Address - Phone:402-391-2001
Mailing Address - Fax:402-391-2004
Practice Address - Street 1:600 N 93RD ST
Practice Address - Street 2:SUITE 100
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-2697
Practice Address - Country:US
Practice Address - Phone:402-391-2001
Practice Address - Fax:402-391-2004
Is Sole Proprietor?:No
Enumeration Date:2013-08-06
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE3260225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10026202000Medicaid