Provider Demographics
NPI:1790208403
Name:LEE, JESSICA S
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:S
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 1:985 INTERVALE AVE APT 2C
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10459-3166
Mailing Address - Country:US
Mailing Address - Phone:646-796-4675
Mailing Address - Fax:
Practice Address - Street 1:985 INTERVALE AVE APT. 2C
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10459
Practice Address - Country:US
Practice Address - Phone:646-796-4675
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency