Basic Information
| Provider Information | |||||||||
| NPI: | 1316154768 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEWIS | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MHS, LPC, CAC, CCS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 264 | ||||||||
| Address2: | |||||||||
| City: | NORRISTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194040264 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6103162887 | ||||||||
| FaxNumber: | 2154384159 | ||||||||
| Practice Location | |||||||||
| Address1: | 85 E SPRING AVE | ||||||||
| Address2: | |||||||||
| City: | ARDMORE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190032143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6103162887 | ||||||||
| FaxNumber: | 2154384159 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2007 | ||||||||
| LastUpdateDate: | 03/03/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | PC000948 | PA | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 1316154768 | 05 | PA | MEDICAID |