Provider Demographics
NPI:1063084234
Name:LEWIS, JALISA
Entity type:Individual
Prefix:
First Name:JALISA
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12115 LEMMOND FARM DR APT 1101
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28227-8191
Mailing Address - Country:US
Mailing Address - Phone:919-222-6052
Mailing Address - Fax:
Practice Address - Street 1:12115 LEMMOND FARM DR APT 1101
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28227-8191
Practice Address - Country:US
Practice Address - Phone:919-222-6052
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-15
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0129331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical