Provider Demographics
NPI:1902818586
Name:JEWETT, LISA R (PT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:R
Last Name:JEWETT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:23825 COMMERCE PARK
Mailing Address - Street 2:SUITE B
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-5837
Mailing Address - Country:US
Mailing Address - Phone:216-292-6363
Mailing Address - Fax:216-292-6306
Practice Address - Street 1:15900 SNOW RD
Practice Address - Street 2:
Practice Address - City:BROOK PARK
Practice Address - State:OH
Practice Address - Zip Code:44142-2859
Practice Address - Country:US
Practice Address - Phone:216-265-3454
Practice Address - Fax:216-267-5553
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT-4377225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist