Healthcare Provider Details

I. General information

NPI: 1821363060
Provider Name (Legal Business Name): JULIE JACKSON LEWIS CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JULIE LATRACE JACKSON

II. Dates (important events)

Enumeration Date: 03/21/2012
Last Update Date: 10/28/2022
Certification Date: 10/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5353 REYNOLDS ST
SAVANNAH GA
31405-6015
US

IV. Provider business mailing address

11511 SHADOW CREEK PKWY
PEARLAND TX
77584-7298
US

V. Phone/Fax

Practice location:
  • Phone: 912-819-6000
  • Fax:
Mailing address:
  • Phone: 713-442-0000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP128105
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN176488
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: