MEDICARE: MS. JAN HENDRICK LEWIS L.C.S.W.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	LSW0000003451	TN

General Provider Information

NPI Number	:	1013158864
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JAN HENDRICK LEWIS L.C.S.W.

Provider Business Mailing Address
First Line	:	1002 BRADFORD WAY
Second Line	:
City	:	KINGSTON
State	:	TN
Zip	:	37763-3100
Country	:	US
Telephone Number	:	865-376-1585
Fax Number	:	865-376-1587

Provider Business Practice Location Address
First Line	:	1002 BRADFORD WAY
Second Line	:
City	:	KINGSTON
State	:	TN
Zip	:	37763-3100
Country	:	US
Telephone Number	:	865-376-1585
Fax Number	:	865-376-1587

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/07/2009
Last Update Date	:	03/07/2009

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