Provider Demographics
NPI:1689448128
Name:LEE, MICHAEL JASON
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JASON
Last Name:LEE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 PAR LN STE 102
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-9023
Mailing Address - Country:US
Mailing Address - Phone:270-320-2605
Mailing Address - Fax:
Practice Address - Street 1:100 PAR LN STE 102
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-9023
Practice Address - Country:US
Practice Address - Phone:270-320-2605
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-14
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist