Provider Demographics
NPI:1023360260
Name:LEE, JESSE NEWTON (CRNA)
Entity Type:Individual
Prefix:MR
First Name:JESSE
Middle Name:NEWTON
Last Name:LEE
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 EXETER RD
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-2954
Mailing Address - Country:US
Mailing Address - Phone:901-818-2160
Mailing Address - Fax:
Practice Address - Street 1:1900 EXETER RD
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-2954
Practice Address - Country:US
Practice Address - Phone:901-818-2160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-12
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN190871163W00000X
TN17054367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
1023360260OtherCHAMPUS/TRICARE
MS02509086Medicaid
TN12497024Medicaid
AR195879003Medicaid
TN4338105OtherBCBST
TN12497024Medicaid