=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316305972
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JASON LEWIS CDP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/10/2016
-----------------------------------------------------
Last Update Date | 02/10/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1016 SO 28TH ST
-----------------------------------------------------
City | TACOMA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98409-8020
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-593-2844
-----------------------------------------------------
Fax | 253-759-5296
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1016 SO 28TH ST
-----------------------------------------------------
City | TACOMA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98409-8020
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-593-2844
-----------------------------------------------------
Fax | 253-759-5296
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | CP00006201
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------