Provider Demographics
NPI:1609519222
Name:LEE, JENNIFER BOEUN
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:BOEUN
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 1:175 W 95TH ST APT 21H
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-7163
Mailing Address - Country:US
Mailing Address - Phone:617-429-2541
Mailing Address - Fax:
Practice Address - Street 1:175 W 95TH ST APT 21H
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-7163
Practice Address - Country:US
Practice Address - Phone:617-429-2541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-20
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY113102-011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical