Provider Demographics
NPI:1144794991
Name:JEWETT, LISA LEETTA (RADT)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:LEETTA
Last Name:JEWETT
Suffix:
Gender:F
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2937 TOGNINALI LN
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95206-6028
Mailing Address - Country:US
Mailing Address - Phone:408-508-2178
Mailing Address - Fax:
Practice Address - Street 1:750 SPAANS DR STE CD&F
Practice Address - Street 2:
Practice Address - City:GALT
Practice Address - State:CA
Practice Address - Zip Code:95632-8609
Practice Address - Country:US
Practice Address - Phone:209-744-9909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-15
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1310170618101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)