Healthcare Provider Details

I. General information

NPI: 1104975440
Provider Name (Legal Business Name): JASON LEWIS PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 03/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3440 MARKET ST SUITE 200
PHILADELPHIA PA
19104-3325
US

IV. Provider business mailing address

301 LINDENWOOD DR SUITE 350
MALVERN PA
19355-1758
US

V. Phone/Fax

Practice location:
  • Phone: 215-590-7555
  • Fax: 215-590-4251
Mailing address:
  • Phone: 215-590-2897
  • Fax: 215-590-0325

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number016779-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPS016826
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: