Provider Demographics
NPI:1417008145
Name:LEE, JISON ELLEN (LPC)
Entity Type:Individual
Prefix:MRS
First Name:JISON
Middle Name:ELLEN
Last Name:LEE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2550 BLAISDELL AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404
Mailing Address - Country:US
Mailing Address - Phone:612-532-9100
Mailing Address - Fax:612-813-5399
Practice Address - Street 1:2550 BLAISDELL AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404
Practice Address - Country:US
Practice Address - Phone:612-532-9100
Practice Address - Fax:612-813-5399
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2009-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLPC00683101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP1-089-7373-0OtherBCBS PIN