Provider Demographics
NPI:1700815446
Name:LEWIS, JENNIFER BRACKETT (PT, AT,C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:BRACKETT
Last Name:LEWIS
Suffix:
Gender:F
Credentials:PT, AT,C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12 DAWSON MARKET WAY STE 320
Practice Address - Street 2:
Practice Address - City:DAWSONVILLE
Practice Address - State:GA
Practice Address - Zip Code:30534-7296
Practice Address - Country:US
Practice Address - Phone:470-759-2415
Practice Address - Fax:706-441-3321
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT005634225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52183607002OtherBCBS MARIETTA LOCATION
GA52183607001OtherBCBS AUSTELL LOCATION
GA52183607003OtherBCBS WOODSTOCK LOCATION
GA52183607004OtherBCBS DOUGLASVILLE LOCATIO
GA52183607002OtherBCBS MARIETTA LOCATION
GA52183607001OtherBCBS AUSTELL LOCATION