Provider Demographics
NPI:1689288649
Name:LEE, JAE JEONG GLORIA (DAOM)
Entity Type:Individual
Prefix:
First Name:JAE JEONG
Middle Name:GLORIA
Last Name:LEE
Suffix:
Gender:F
Credentials:DAOM
Other - Prefix:
Other - First Name:GLORIA
Other - Middle Name:
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:32 LORRAINE METCALF RD
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:MA
Mailing Address - Zip Code:02038-3234
Mailing Address - Country:US
Mailing Address - Phone:860-460-9074
Mailing Address - Fax:
Practice Address - Street 1:136A W MAIN RD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:RI
Practice Address - Zip Code:02842-4937
Practice Address - Country:US
Practice Address - Phone:401-862-4894
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-07
Last Update Date:2020-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133N00000X
RIDA00468171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No133N00000XDietary & Nutritional Service ProvidersNutritionist