Provider Demographics
NPI:1265108039
Name:LEWIS, JESSICA ADRIANNE
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ADRIANNE
Last Name:LEWIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:LEWIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:599 MYRTLE BEACH DR
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:94513-5616
Mailing Address - Country:US
Mailing Address - Phone:925-813-9944
Mailing Address - Fax:
Practice Address - Street 1:1255 ALLSTON WAY
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94702-1833
Practice Address - Country:US
Practice Address - Phone:510-849-1402
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-20
Last Update Date:2021-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program