Provider Demographics
NPI:1154098366
Name:LEE, JACQUELINE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6310 BROWNS MILL RD
Mailing Address - Street 2:
Mailing Address - City:STONECREST
Mailing Address - State:GA
Mailing Address - Zip Code:30038-4209
Mailing Address - Country:US
Mailing Address - Phone:321-557-6041
Mailing Address - Fax:
Practice Address - Street 1:6310 BROWNS MILL RD
Practice Address - Street 2:
Practice Address - City:STONECREST
Practice Address - State:GA
Practice Address - Zip Code:30038-4209
Practice Address - Country:US
Practice Address - Phone:321-557-6041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-25
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN095403164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse