Provider Demographics
NPI:1982431177
Name:LEWIS, JASON EMMANUEL
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:EMMANUEL
Last Name:LEWIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1819 CHARLIE SIFFORD DR
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90047-5102
Mailing Address - Country:US
Mailing Address - Phone:310-901-0446
Mailing Address - Fax:
Practice Address - Street 1:879 W 190TH ST STE 1000
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90248-4255
Practice Address - Country:US
Practice Address - Phone:310-329-9115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-19
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician