Provider Demographics
NPI:1225371065
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:PO BOX 3202
Mailing Address - Street 2:
Mailing Address - City:PLACIDA
Mailing Address - State:FL
Mailing Address - Zip Code:33946-3202
Mailing Address - Country:US
Mailing Address - Phone:941-661-2643
Mailing Address - Fax:
Practice Address - Street 1:45 CADDY RD
Practice Address - Street 2:
Practice Address - City:ROTONDA WEST
Practice Address - State:FL
Practice Address - Zip Code:33947-2217
Practice Address - Country:US
Practice Address - Phone:941-661-2643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-29
Last Update Date:2013-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL232306251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL689465896Medicaid