Provider Demographics
NPI:1346622792
Name:LEE, JAE EUN
Entity Type:Individual
Prefix:
First Name:JAE EUN
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 1:201 PARK ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-1708
Mailing Address - Country:US
Mailing Address - Phone:270-781-5111
Mailing Address - Fax:270-783-3774
Practice Address - Street 1:201 PARK ST
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-1708
Practice Address - Country:US
Practice Address - Phone:270-783-3315
Practice Address - Fax:270-783-3774
Is Sole Proprietor?:No
Enumeration Date:2015-06-22
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN655472084N0400X
KY546552084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology