Provider Demographics
NPI:1679953012
Name:LEE, JENNA (LLMSW, QIDP)
Entity Type:Individual
Prefix:MISS
First Name:JENNA
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:LLMSW, QIDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 LEONARD ST NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-1138
Mailing Address - Country:US
Mailing Address - Phone:616-588-7221
Mailing Address - Fax:616-774-1001
Practice Address - Street 1:805 LEONARD ST NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-1138
Practice Address - Country:US
Practice Address - Phone:616-588-7221
Practice Address - Fax:616-774-1001
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-01
Last Update Date:2015-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010959161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical