=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275343543
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JENNIFER LEWIS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/09/2025
-----------------------------------------------------
Last Update Date | 01/09/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1505 CARTER AVE STE 104
-----------------------------------------------------
City | ASHLAND
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41101-7672
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-547-1716
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4678 NOTTINGHAM CT
-----------------------------------------------------
City | ASHLAND
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41101-6830
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-547-1716
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | THERAPIST
-----------------------------------------------------
Name | MRS. JENNIFER NICOLE LEWIS
-----------------------------------------------------
Credential | MSW, LCSW
-----------------------------------------------------
Telephone | 606-547-1716
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------