Provider Demographics
NPI:1942524046
Name:LEWIS, JASON L (PHD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:L
Last Name:LEWIS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10513 HIDDEN OAKS LN N
Mailing Address - Street 2:
Mailing Address - City:CHAMPLIN
Mailing Address - State:MN
Mailing Address - Zip Code:55316-3045
Mailing Address - Country:US
Mailing Address - Phone:763-951-3252
Mailing Address - Fax:
Practice Address - Street 1:10513 HIDDEN OAKS LN N
Practice Address - Street 2:
Practice Address - City:CHAMPLIN
Practice Address - State:MN
Practice Address - Zip Code:55316-3045
Practice Address - Country:US
Practice Address - Phone:763-951-3252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-17
Last Update Date:2010-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4841103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical