Provider Demographics
NPI:1245341361
Name:LEWIS, JESSICA (MA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:WALKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, CCC-SLP
Mailing Address - Street 1:PO BOX 1599
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04402-1599
Mailing Address - Country:US
Mailing Address - Phone:207-945-5247
Mailing Address - Fax:207-947-0435
Practice Address - Street 1:175 UNION ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401
Practice Address - Country:US
Practice Address - Phone:207-941-2850
Practice Address - Fax:207-941-2852
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2010-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MESP1546235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME410260099Medicaid
ME061377OtherANTHEM BLUE CROSS AND BLU
ME410260099Medicaid