Provider Demographics
NPI:1962192229
Name:LEWIS, JESSICA (MA, RMHCI)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:MA, RMHCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12137 ENSLEY AVE
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:FL
Mailing Address - Zip Code:34667-2914
Mailing Address - Country:US
Mailing Address - Phone:248-303-3730
Mailing Address - Fax:
Practice Address - Street 1:1501 S PINELLAS AVE STE QANDH
Practice Address - Street 2:
Practice Address - City:TARPON SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34689-1955
Practice Address - Country:US
Practice Address - Phone:727-219-1752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-10
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH23998101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health