Provider Demographics
NPI:1710530712
Name:LEE, JESSICA GRAY
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:GRAY
Last Name:LEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 JOHNSTON ST SE STE 200
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35601-2515
Mailing Address - Country:US
Mailing Address - Phone:256-350-1764
Mailing Address - Fax:
Practice Address - Street 1:241 ROBERT K WILSON DR
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:AL
Practice Address - Zip Code:35447-8032
Practice Address - Country:US
Practice Address - Phone:205-367-2468
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-18
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3402235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist