Healthcare Provider Details

I. General information

NPI: 1619296340
Provider Name (Legal Business Name): JACQUELYN AMERA LEWCHALERMWONG M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2010
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1117 APPLE VALLEY RD
MADISON TN
37115-2305
US

IV. Provider business mailing address

PO BOX 645
INDEPENDENCE VA
24348-0645
US

V. Phone/Fax

Practice location:
  • Phone: 310-953-1919
  • Fax:
Mailing address:
  • Phone: 310-953-1919
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2014-01801
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA118019
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD-R-8813
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: