Provider Demographics
NPI:1851595763
Name:LEWIS, JEFFERSON D (MA, MDIV)
Entity Type:Individual
Prefix:MR
First Name:JEFFERSON
Middle Name:D
Last Name:LEWIS
Suffix:
Gender:M
Credentials:MA, MDIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 VALKYRIE CIR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29229-3390
Mailing Address - Country:US
Mailing Address - Phone:803-730-3746
Mailing Address - Fax:803-736-4619
Practice Address - Street 1:31 VALKYRIE CIR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29229-3390
Practice Address - Country:US
Practice Address - Phone:803-730-3746
Practice Address - Fax:803-736-4619
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-13
Last Update Date:2015-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4616101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional