Provider Demographics
NPI:1073833182
Name:LEE, JASON BENNELL
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:BENNELL
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 1:4560 CIRCLE LAZY J RD
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92501-2043
Mailing Address - Country:US
Mailing Address - Phone:951-682-1257
Mailing Address - Fax:
Practice Address - Street 1:4560 CIRCLE LAZY J RD
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-2043
Practice Address - Country:US
Practice Address - Phone:951-682-1257
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-11
Last Update Date:2010-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health