Provider Demographics
NPI:1932182128
Name:JEWELL MICHAEL, LISA (PHD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:JEWELL MICHAEL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:A
Other - Last Name:JEWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:314 N PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:MONTPELIER
Mailing Address - State:OH
Mailing Address - Zip Code:43543-1150
Mailing Address - Country:US
Mailing Address - Phone:419-551-2720
Mailing Address - Fax:
Practice Address - Street 1:22251 STATE ROUTE 2
Practice Address - Street 2:
Practice Address - City:ARCHBOLD
Practice Address - State:OH
Practice Address - Zip Code:43502-9452
Practice Address - Country:US
Practice Address - Phone:419-445-1552
Practice Address - Fax:419-445-1401
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6062103T00000X
OHP.6062103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist