Provider Demographics
NPI:1205231362
Name:LEE, JAYSON DEW (REGISTERED COUNSELOR)
Entity Type:Individual
Prefix:MR
First Name:JAYSON
Middle Name:DEW
Last Name:LEE
Suffix:
Gender:M
Credentials:REGISTERED COUNSELOR
Other - Prefix:MR
Other - First Name:JAYSON
Other - Middle Name:DEW
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RRW
Mailing Address - Street 1:470 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90013-1629
Mailing Address - Country:US
Mailing Address - Phone:213-626-6411
Mailing Address - Fax:
Practice Address - Street 1:470 E 3RD ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90013-1629
Practice Address - Country:US
Practice Address - Phone:213-626-6411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-30
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA190100E101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA190100EMedicaid