Provider Demographics
NPI:1760910186
Name:JEWETT, LAUREN (PA-C)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:JEWETT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3801 WILLIAM D TATE AVE STE 800A
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-8755
Mailing Address - Country:US
Mailing Address - Phone:817-488-8998
Mailing Address - Fax:
Practice Address - Street 1:3801 WILLIAM D TATE AVE STE 800A
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-8755
Practice Address - Country:US
Practice Address - Phone:817-488-8998
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-30
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA11256363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant