Provider Demographics
NPI:1255522694
Name:LEWALLEN, JINA PHILLIPS (PHD, LCSW, MA)
Entity type:Individual
Prefix:DR
First Name:JINA
Middle Name:PHILLIPS
Last Name:LEWALLEN
Suffix:
Gender:F
Credentials:PHD, LCSW, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26493 E UNIVERSITY DR APT 1148
Mailing Address - Street 2:
Mailing Address - City:AUBREY
Mailing Address - State:TX
Mailing Address - Zip Code:76227-1675
Mailing Address - Country:US
Mailing Address - Phone:501-317-8417
Mailing Address - Fax:
Practice Address - Street 1:26493 E UNIVERSITY DR APT 1148
Practice Address - Street 2:
Practice Address - City:AUBREY
Practice Address - State:TX
Practice Address - Zip Code:76227-1675
Practice Address - Country:US
Practice Address - Phone:501-317-8417
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2142-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARP00428989OtherRAILROAD MEDICARE
AR1255522694Medicaid