Provider Demographics
NPI:1629090048
Name:LEE, JEANETTE (OD)
Entity Type:Individual
Prefix:DR
First Name:JEANETTE
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2555 N 1ST ST
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95131-1003
Mailing Address - Country:US
Mailing Address - Phone:408-433-0800
Mailing Address - Fax:408-577-0849
Practice Address - Street 1:2555 N 1ST ST
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95131-1003
Practice Address - Country:US
Practice Address - Phone:408-433-0800
Practice Address - Fax:408-577-0849
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10538T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU53514Medicare UPIN