Provider Demographics
NPI:1033462999
Name:LEE, JENNIFER LOUISE (NP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LOUISE
Last Name:LEE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LOUISE
Other - Last Name:FLEMING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP-PP ADULT
Mailing Address - Street 1:2020 CAPITOL ST NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-0644
Mailing Address - Country:US
Mailing Address - Phone:503-339-2424
Mailing Address - Fax:
Practice Address - Street 1:5100 RIVER RD N
Practice Address - Street 2:
Practice Address - City:KEIZER
Practice Address - State:OR
Practice Address - Zip Code:97303-5371
Practice Address - Country:US
Practice Address - Phone:503-933-2533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-17
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201250175NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500651188Medicaid
OR1228590005Medicare NSC
ORR167458Medicare PIN