Basic Information
| Provider Information | |||||||||
| NPI: | 1659721496 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEWIS | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | D. | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2585 3RD AVE | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257031642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046971396 | ||||||||
| FaxNumber: | 3046972086 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 HARBOUR WAY | ||||||||
| Address2: | |||||||||
| City: | MILTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047431407 | ||||||||
| FaxNumber: | 3047434516 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2016 | ||||||||
| LastUpdateDate: | 08/07/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 71360 | WV | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1659721496 | 05 | WV | MEDICAID | 0295267 | 05 | OH | MEDICAID |