=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255052221
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNA MARIE LEWIS DPT, PHD, WCS, CLT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/08/2022
-----------------------------------------------------
Last Update Date | 09/08/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2418 E YORK ST
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19125-3006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 267-570-3603
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13 E NARBERTH TER
-----------------------------------------------------
City | COLLINGSWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08108-1016
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-608-3471
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PA027220
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------