Provider Demographics
NPI:1164503561
Name:LEE, JENNIFER ANNETTE (MT(ASCP))
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:ANNETTE
Last Name:LEE
Suffix:
Gender:F
Credentials:MT(ASCP)
Other - Prefix:MRS
Other - First Name:JENNIFER
Other - Middle Name:GRANTHAM
Other - Last Name:PROCTOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MT(ASCP)
Mailing Address - Street 1:355 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:MOCKSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27028-2143
Mailing Address - Country:US
Mailing Address - Phone:336-751-1659
Mailing Address - Fax:
Practice Address - Street 1:190 KIMEL PARK DRIVE
Practice Address - Street 2:VA OUTPATIENT CLINIC
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103
Practice Address - Country:US
Practice Address - Phone:336-768-3296
Practice Address - Fax:336-760-5481
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMT-175524246QM0706X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246QM0706XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyMedical Technologist