Provider Demographics
NPI:1922300094
Name:LEE, JESSICA SEULGII (PT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:SEULGII
Last Name:LEE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 NORTHERN BLVD
Mailing Address - Street 2:SUITE 11
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-4802
Mailing Address - Country:US
Mailing Address - Phone:516-466-7720
Mailing Address - Fax:516-466-7723
Practice Address - Street 1:475 NORTHERN BLVD
Practice Address - Street 2:SUITE 11
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-4802
Practice Address - Country:US
Practice Address - Phone:516-466-7720
Practice Address - Fax:516-466-7723
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-23
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033267225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist