Provider Demographics
NPI:1033502869
Name:LEE, JENNIFER EUN JOO (DO)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:EUN JOO
Last Name:LEE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:EUN JOO
Other - Middle Name:
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:1147 RED TAIL WAY
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-7232
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1147 RED TAIL WAY
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-7232
Practice Address - Country:US
Practice Address - Phone:805-527-8055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-18
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A17453207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology