Provider Demographics
NPI:1104975440
Name:LEWIS, JASON (PHD)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:LEWIS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 LINDENWOOD DR
Mailing Address - Street 2:SUITE 350
Mailing Address - City:MALVERN
Mailing Address - State:PA
Mailing Address - Zip Code:19355-1758
Mailing Address - Country:US
Mailing Address - Phone:215-590-2897
Mailing Address - Fax:215-590-0325
Practice Address - Street 1:3440 MARKET ST
Practice Address - Street 2:SUITE 200
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-3325
Practice Address - Country:US
Practice Address - Phone:215-590-7555
Practice Address - Fax:215-590-4251
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016779-1103T00000X
PAPS016826103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist