Provider Demographics
NPI:1427535657
Name:LEE, JENNIFER MYUNG
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MYUNG
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 1:3233 BAGLEY PSGE
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30097-3790
Mailing Address - Country:US
Mailing Address - Phone:239-822-2075
Mailing Address - Fax:
Practice Address - Street 1:1017 FAYETTEVILLE RD SE STE B
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30316-2932
Practice Address - Country:US
Practice Address - Phone:404-486-9034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-20
Last Update Date:2018-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA$$$$$$$$$Medicaid