Provider Demographics
NPI:1447492673
Name:LEWIS, JEREMY DAVID (MSED, LMFT)
Entity type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:DAVID
Last Name:LEWIS
Suffix:
Gender:M
Credentials:MSED, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 562
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:IN
Mailing Address - Zip Code:46706-0562
Mailing Address - Country:US
Mailing Address - Phone:260-925-3865
Mailing Address - Fax:260-925-3892
Practice Address - Street 1:1752 WESLEY RD
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:IN
Practice Address - Zip Code:46706-3646
Practice Address - Country:US
Practice Address - Phone:260-925-3865
Practice Address - Fax:206-925-3892
Is Sole Proprietor?:No
Enumeration Date:2009-04-02
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN35001668A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist