Provider Demographics
NPI:1134475023
Name:LEE, JESSIE K (OD)
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:K
Last Name:LEE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7677 OAKPORT ST STE 100
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94621-1939
Mailing Address - Country:US
Mailing Address - Phone:510-383-8830
Mailing Address - Fax:
Practice Address - Street 1:7677 OAKPORT ST STE 100
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94621-1939
Practice Address - Country:US
Practice Address - Phone:510-383-8830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-28
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14468152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist