Healthcare Provider Details

I. General information

NPI: 1215481825
Provider Name (Legal Business Name): JONATHAN LEWIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2016
Last Update Date: 12/18/2023
Certification Date: 12/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9890 COUNTY FARM RD STE 3
RIVERSIDE CA
92503-3678
US

IV. Provider business mailing address

1701 MISSION AVE SUITE A
OCEANSIDE CA
92058-7102
US

V. Phone/Fax

Practice location:
  • Phone: 951-509-8320
  • Fax: 951-509-8322
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number100910
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: