Basic Information
| Provider Information | |||||||||
| NPI: | 1265108039 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEWIS | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | ADRIANNE | ||||||||
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| Credential: | |||||||||
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| OtherLastName: | LEWIS | ||||||||
| OtherFirstName: | JESSICA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 599 MYRTLE BEACH DR | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945135616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9258139944 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1255 ALLSTON WAY | ||||||||
| Address2: | |||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 947021833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5108491402 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2021 | ||||||||
| LastUpdateDate: | 09/12/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.