Provider Demographics
NPI:1902955511
Name:LEWIS, JESSE F (PHD)
Entity Type:Individual
Prefix:DR
First Name:JESSE
Middle Name:F
Last Name:LEWIS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3540 WHEELER RD STE 415
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-1888
Mailing Address - Country:US
Mailing Address - Phone:706-738-7000
Mailing Address - Fax:
Practice Address - Street 1:3540 WHEELER RD STE 415
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-1888
Practice Address - Country:US
Practice Address - Phone:706-738-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000477103T00000X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent