Provider Demographics
NPI:1295261865
Name:LEWIS, JENNIFER RENEE
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RENEE
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 1:300 TWINING ST BLDG 760
Mailing Address - Street 2:
Mailing Address - City:MAXWELL AFB
Mailing Address - State:AL
Mailing Address - Zip Code:36112-6027
Mailing Address - Country:US
Mailing Address - Phone:334-953-3368
Mailing Address - Fax:
Practice Address - Street 1:300 TWINING ST BLDG 760
Practice Address - Street 2:
Practice Address - City:MAXWELL AFB
Practice Address - State:AL
Practice Address - Zip Code:36112
Practice Address - Country:US
Practice Address - Phone:334-953-3368
Practice Address - Fax:334-953-8607
Is Sole Proprietor?:No
Enumeration Date:2017-05-02
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
AL1441363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant