Provider Demographics
NPI:1790368272
Name:LEWIS, STEPHON JORDAN (PLPC)
Entity Type:Individual
Prefix:
First Name:STEPHON
Middle Name:JORDAN
Last Name:LEWIS
Suffix:
Gender:M
Credentials:PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5306 W 71ST TER
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE VILLAGE
Mailing Address - State:KS
Mailing Address - Zip Code:66208-2335
Mailing Address - Country:US
Mailing Address - Phone:816-522-4458
Mailing Address - Fax:
Practice Address - Street 1:1601 E 18TH ST
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64108-1680
Practice Address - Country:US
Practice Address - Phone:816-522-4458
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-03
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021015291101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2021015291Medicaid