Provider Demographics
NPI:1184369266
Name:LEWIS, JOHN EDWARD
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:EDWARD
Last Name:LEWIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6766 W ULYSSES PL
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84081-4217
Mailing Address - Country:US
Mailing Address - Phone:801-870-8306
Mailing Address - Fax:
Practice Address - Street 1:11260 S RIVER HEIGHTS DR
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-5119
Practice Address - Country:US
Practice Address - Phone:801-298-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-03
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health