Provider Demographics
NPI:1407071178
Name:LEE, JACINTA C (RD)
Entity Type:Individual
Prefix:MRS
First Name:JACINTA
Middle Name:C
Last Name:LEE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6651 E SMOKEWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92807-5039
Mailing Address - Country:US
Mailing Address - Phone:714-470-9732
Mailing Address - Fax:
Practice Address - Street 1:441 N LAKEVIEW AVE
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92807-3028
Practice Address - Country:US
Practice Address - Phone:714-279-4375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA707207133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA707207OtherREGISTERED DIETITIAN