Provider Demographics
NPI:1013147404
Name:LEE-DICK, JENNIFER SARA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:SARA
Last Name:LEE-DICK
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 W SIERRA MADRE BLVD
Mailing Address - Street 2:
Mailing Address - City:SIERRA MADRE
Mailing Address - State:CA
Mailing Address - Zip Code:91024-2364
Mailing Address - Country:US
Mailing Address - Phone:626-539-2001
Mailing Address - Fax:
Practice Address - Street 1:505 W SIERRA MADRE BLVD
Practice Address - Street 2:
Practice Address - City:SIERRA MADRE
Practice Address - State:CA
Practice Address - Zip Code:91024-2364
Practice Address - Country:US
Practice Address - Phone:626-539-2001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-20
Last Update Date:2014-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSB94020558103TC0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical