Provider Demographics
NPI:1578577516
Name:LEE, JENNIFER Y (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:Y
Last Name:LEE
Suffix:
Gender:F
Credentials:MD
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 5127
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98206-5127
Mailing Address - Country:US
Mailing Address - Phone:425-258-3903
Mailing Address - Fax:
Practice Address - Street 1:15418 MAIN ST
Practice Address - Street 2:
Practice Address - City:MILL CREEK
Practice Address - State:WA
Practice Address - Zip Code:98012-9030
Practice Address - Country:US
Practice Address - Phone:425-225-8012
Practice Address - Fax:425-225-8020
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00046846207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1013692Medicaid
WAMD00046846OtherLICENSE
WAMD00046846OtherLICENSE