Provider Demographics
NPI:1164217303
Name:LEWIS, JODIE L
Entity type:Individual
Prefix:
First Name:JODIE
Middle Name:L
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 1:18475 LAWRENCE 2100
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:MO
Mailing Address - Zip Code:65712-8169
Mailing Address - Country:US
Mailing Address - Phone:417-366-0911
Mailing Address - Fax:
Practice Address - Street 1:731 HASTINGS ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:MO
Practice Address - Zip Code:65712-1077
Practice Address - Country:US
Practice Address - Phone:417-366-4654
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-09
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023022867225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist