Provider Demographics
NPI:1508446618
Name:LEE-JACKSON, JUDITH (DO)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:
Last Name:LEE-JACKSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 34213
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68134-0213
Mailing Address - Country:US
Mailing Address - Phone:402-213-4222
Mailing Address - Fax:
Practice Address - Street 1:14605 N 84TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68122-1999
Practice Address - Country:US
Practice Address - Phone:402-213-4222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-12
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NENFOCUS-20664253Z00000X
253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care