Provider Demographics
NPI:1124874607
Name:LEWIS, JACOB DWAYNE
Entity type:Individual
Prefix:MR
First Name:JACOB
Middle Name:DWAYNE
Last Name:LEWIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 W PEACHTREE ST NW STE 2625
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-3499
Mailing Address - Country:US
Mailing Address - Phone:470-634-2692
Mailing Address - Fax:888-816-8882
Practice Address - Street 1:8179 TRACE CT
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-4318
Practice Address - Country:US
Practice Address - Phone:470-634-2692
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-25
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)