Basic Information
| Provider Information | |||||||||
| NPI: | 1821579616 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEWIS | ||||||||
| FirstName: | JACHARRI | ||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HUGHES | ||||||||
| OtherFirstName: | JACHARRI | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3253 CONGRESS AVE | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486023106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9894754171 | ||||||||
| FaxNumber: | 9894754171 | ||||||||
| Practice Location | |||||||||
| Address1: | 3253 CONGRESS AVE | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486023106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9894754171 | ||||||||
| FaxNumber: | 9894754171 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2018 | ||||||||
| LastUpdateDate: | 08/11/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6801107383 | MI | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 6801115082 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.