Provider Demographics
NPI:1760514079
Name:LEWIS, JERMAINE MICHAEL
Entity Type:Individual
Prefix:MR
First Name:JERMAINE
Middle Name:MICHAEL
Last Name:LEWIS
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:JERMAINE
Other - Middle Name:
Other - Last Name:LEWIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:820 E AVE J-12
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93535
Mailing Address - Country:US
Mailing Address - Phone:661-316-2759
Mailing Address - Fax:
Practice Address - Street 1:44443 N DIVISION ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534
Practice Address - Country:US
Practice Address - Phone:661-316-2759
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA-5369101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA-5369Medicare UPIN