Provider Demographics
NPI:1245500768
Name:LEWIS, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:LEWIS
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 1:428 QUEEN ANN CT
Mailing Address - Street 2:
Mailing Address - City:PINEY FLATS
Mailing Address - State:TN
Mailing Address - Zip Code:37686-4228
Mailing Address - Country:US
Mailing Address - Phone:276-525-5129
Mailing Address - Fax:
Practice Address - Street 1:140 TECHNOLOGY LN
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-2004
Practice Address - Country:US
Practice Address - Phone:423-434-2016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-02
Last Update Date:2020-08-28
Deactivation Date:2020-08-14
Deactivation Code:
Reactivation Date:2020-08-28
Provider Licenses
StateLicense IDTaxonomies
TN2422224Z00000X
KYA4289224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant