Provider Demographics
NPI:1013214287
Name:LEE, JAE
Entity Type:Individual
Prefix:
First Name:JAE
Middle Name:
Last Name:LEE
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 1:3624 DUNBAR LN
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-7411
Mailing Address - Country:US
Mailing Address - Phone:678-907-1587
Mailing Address - Fax:678-823-6923
Practice Address - Street 1:1630 PLEASANT HILL RD
Practice Address - Street 2:#B11
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096
Practice Address - Country:US
Practice Address - Phone:678-894-2161
Practice Address - Fax:678-823-6923
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-23
Last Update Date:2011-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALDO002349156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician