Provider Demographics
NPI:1053050187
Name:LEE, JACKY
Entity Type:Individual
Prefix:
First Name:JACKY
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3181 SW SAM JACKSON PARK RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3011
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:OHSU HOSPITAL
Practice Address - Street 2:3181 SW SAM JACKSON PARK RD
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239
Practice Address - Country:US
Practice Address - Phone:503-494-8311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-27
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-00189221835C0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835C0205XPharmacy Service ProvidersPharmacistCritical Care