Provider Demographics
NPI:1396166732
Name:LEWIS, JILL T (MSPT)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:T
Last Name:LEWIS
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1401
Mailing Address - Street 2:
Mailing Address - City:TAPPAHANNOCK
Mailing Address - State:VA
Mailing Address - Zip Code:22560-1401
Mailing Address - Country:US
Mailing Address - Phone:804-443-4850
Mailing Address - Fax:
Practice Address - Street 1:900 SOUTH CHURCH LANE
Practice Address - Street 2:
Practice Address - City:TAPPAHANNOCK
Practice Address - State:VA
Practice Address - Zip Code:22560
Practice Address - Country:US
Practice Address - Phone:804-443-4851
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-03
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2305006664OtherVIRGINIA STATE MEDICAL LICENSE
VA1396166732Medicaid
VAQ45825AMedicare PIN