Healthcare Provider Details

I. General information

NPI: 1083475578
Provider Name (Legal Business Name): REGINA S WILCOX-LEWIS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: REGINA S LEWIS LCSW

II. Dates (important events)

Enumeration Date: 01/22/2024
Last Update Date: 05/14/2024
Certification Date: 05/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 CARL CIR
BYRAM MS
39272-4507
US

IV. Provider business mailing address

350 W WOODROW WILSON AVE
JACKSON MS
39213-7681
US

V. Phone/Fax

Practice location:
  • Phone: 601-946-0369
  • Fax:
Mailing address:
  • Phone: 601-815-3305
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC11021
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: