Healthcare Provider Details

I. General information

NPI: 1164348116
Provider Name (Legal Business Name): JABARI LEWIS
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2026
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 OHIO AVE N STE A
LIVE OAK FL
32064-2464
US

IV. Provider business mailing address

2835 KIRKWOOD CIR
VALDOSTA GA
31602-7125
US

V. Phone/Fax

Practice location:
  • Phone: 305-853-6714
  • Fax:
Mailing address:
  • Phone: 305-853-6714
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number26R-CPT1620
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: