Provider Demographics
NPI:1053066373
Name:LEE, JAE DU
Entity Type:Individual
Prefix:
First Name:JAE
Middle Name:DU
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 1:5332 SEA ISLE RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-5908
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6019 WALNUT GROVE RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2113
Practice Address - Country:US
Practice Address - Phone:901-226-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-15
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN212852163W00000X
390200000X
TN31847367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program