Basic Information
| Provider Information | |||||||||
| NPI: | 1104975440 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEWIS | ||||||||
| FirstName: | JASON | ||||||||
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| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301 LINDENWOOD DR | ||||||||
| Address2: | SUITE 350 | ||||||||
| City: | MALVERN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193551758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155902897 | ||||||||
| FaxNumber: | 2155900325 | ||||||||
| Practice Location | |||||||||
| Address1: | 3440 MARKET ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191043325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155907555 | ||||||||
| FaxNumber: | 2155904251 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2007 | ||||||||
| LastUpdateDate: | 03/19/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 016779-1 | NY | N | Behavioral Health & Social Service Providers | Psychologist | 103T00000X | PS016826 | PA | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.