Healthcare Provider Details

I. General information

NPI: 1730799529
Provider Name (Legal Business Name): MRS. JINSUN LEWIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2020
Last Update Date: 08/06/2020
Certification Date: 08/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6013 S FERDINAND ST
TACOMA WA
98409-1219
US

IV. Provider business mailing address

6013 S FERDINAND ST
TACOMA WA
98409-1219
US

V. Phone/Fax

Practice location:
  • Phone: 253-970-2110
  • Fax:
Mailing address:
  • Phone: 253-970-2110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171R00000X
TaxonomyInterpreter
License NumberSC7251
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code171R00000X
TaxonomyInterpreter
License NumberMC8150
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: