Provider Demographics
NPI:1417100678
Name:LEE, JENNIFER ANN (MA, CCC-A)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:LEE
Suffix:
Gender:F
Credentials:MA, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3084 LINDSAY LN
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-7777
Mailing Address - Country:US
Mailing Address - Phone:810-984-8278
Mailing Address - Fax:
Practice Address - Street 1:3084 LINDSAY LN
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-7777
Practice Address - Country:US
Practice Address - Phone:810-984-8278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-30
Last Update Date:2008-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1601000382231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist