Provider Demographics
NPI:1649916578
Name:LEWIS, JACOB WALTON (LAT, ATC, CKTP)
Entity type:Individual
Prefix:MR
First Name:JACOB
Middle Name:WALTON
Last Name:LEWIS
Suffix:
Gender:M
Credentials:LAT, ATC, CKTP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5735 COLLEGE PARKWAY
Mailing Address - Street 2:
Mailing Address - City:EIGHT MILE
Mailing Address - State:AL
Mailing Address - Zip Code:36613
Mailing Address - Country:US
Mailing Address - Phone:251-442-2561
Mailing Address - Fax:
Practice Address - Street 1:5735 COLLEGE PKWY
Practice Address - Street 2:
Practice Address - City:EIGHT MILE
Practice Address - State:AL
Practice Address - Zip Code:36613-2842
Practice Address - Country:US
Practice Address - Phone:251-442-2561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-12
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL15232255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer