Provider Demographics
NPI:1124088471
Name:LEWIS, JAY L (PHD)
Entity type:Individual
Prefix:
First Name:JAY
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 1:1110 E MISSOURI AVE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-2703
Mailing Address - Country:US
Mailing Address - Phone:602-242-9400
Mailing Address - Fax:602-242-9421
Practice Address - Street 1:1110 E MISSOURI AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-2707
Practice Address - Country:US
Practice Address - Phone:602-242-9400
Practice Address - Fax:602-242-9421
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ774103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZPHD774Medicare ID - Type Unspecified