Provider Demographics
NPI:1962134874
Name:LEWIS, JACQUETTA
Entity type:Individual
Prefix:MS
First Name:JACQUETTA
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 OLD DUNELAND PKWY
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46403-2398
Mailing Address - Country:US
Mailing Address - Phone:312-682-4213
Mailing Address - Fax:
Practice Address - Street 1:413 OLD DUNELAND PKWY
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46403-2398
Practice Address - Country:US
Practice Address - Phone:312-682-4213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-29
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN202206151600328251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health