Provider Demographics
NPI:1083731806
Name:MCGEE, JACK LEE
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:LEE
Last Name:MCGEE
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 1:3100 19TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93301-3149
Mailing Address - Country:US
Mailing Address - Phone:661-322-3937
Mailing Address - Fax:
Practice Address - Street 1:3100 19TH ST STE 100
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93301-3149
Practice Address - Country:US
Practice Address - Phone:661-322-3937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA07 00002439156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADX002788FMedicaid
CA0685360001Medicare ID - Type Unspecified