Provider Demographics
NPI:1104000991
Name:LEE, JEFFREY (MPT)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MITCHELL
Mailing Address - State:SD
Mailing Address - Zip Code:57301-1351
Mailing Address - Country:US
Mailing Address - Phone:605-996-4552
Mailing Address - Fax:605-996-0577
Practice Address - Street 1:1005 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MITCHELL
Practice Address - State:SD
Practice Address - Zip Code:57301-1351
Practice Address - Country:US
Practice Address - Phone:605-996-4552
Practice Address - Fax:605-996-0577
Is Sole Proprietor?:No
Enumeration Date:2007-12-28
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0946225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5833413Medicaid
SDS40992Medicare PIN