Provider Demographics
NPI:1063878312
Name:LEWIS, JENNIFER ROCHELLE (LAT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ROCHELLE
Last Name:LEWIS
Suffix:
Gender:F
Credentials:LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4923 CAPTAINS PL
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75043-6766
Mailing Address - Country:US
Mailing Address - Phone:903-641-8860
Mailing Address - Fax:
Practice Address - Street 1:4923 CAPTAINS PL
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75043-6766
Practice Address - Country:US
Practice Address - Phone:903-641-8860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-01
Last Update Date:2016-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT37472255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer