Provider Demographics
NPI:1154745313
Name:LEWIS, JENNIFER NISHAUN (EDS)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:NISHAUN
Last Name:LEWIS
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:741 SHELLEY PKWY
Mailing Address - Street 2:
Mailing Address - City:BEREA
Mailing Address - State:OH
Mailing Address - Zip Code:44017-1137
Mailing Address - Country:US
Mailing Address - Phone:440-781-1009
Mailing Address - Fax:
Practice Address - Street 1:1312 5TH ST SW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44707-4657
Practice Address - Country:US
Practice Address - Phone:330-580-3517
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-08
Last Update Date:2014-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH3151571103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool