Provider Demographics
NPI:1689158149
Name:LEE, JESSICA (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3085 POLK DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BCH
Mailing Address - State:VA
Mailing Address - Zip Code:23456-7515
Mailing Address - Country:US
Mailing Address - Phone:252-230-0876
Mailing Address - Fax:
Practice Address - Street 1:1413 LASKIN RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23451-6007
Practice Address - Country:US
Practice Address - Phone:252-230-0876
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-20
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202007032235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist