Basic Information
| Provider Information | |||||||||
| NPI: | 1568691186 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JENNIFER M. LEWISTON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 42536 HAYES RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | CLINTON TWP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480383644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5862869644 | ||||||||
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| Practice Location | |||||||||
| Address1: | 42536 HAYES RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | CLINTON TWP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480383644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5862869644 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2009 | ||||||||
| LastUpdateDate: | 07/02/2009 | ||||||||
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| AuthorizedOfficialLastName: | LEWISTON | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
| AuthorizedOfficialMiddleName: | MICHELLE | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DOCTOR | ||||||||
| AuthorizedOfficialTelephone: | 2487091177 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.