Provider Demographics
NPI:1922602648
Name:LEW, JESSICA KELLI
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:KELLI
Last Name:LEW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3080 E CHERRY ST # B302
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65802-2625
Mailing Address - Country:US
Mailing Address - Phone:408-348-9532
Mailing Address - Fax:
Practice Address - Street 1:5667 MONTEZUMA RD APT F
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92115-2319
Practice Address - Country:US
Practice Address - Phone:408-348-9532
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-23
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program