Provider Demographics
NPI:1205241320
Name:LEE, JAE
Entity type:Individual
Prefix:
First Name:JAE
Middle Name:
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 1:12411 OSBORNE ST
Mailing Address - Street 2:UNIT 45
Mailing Address - City:PACOIMA
Mailing Address - State:CA
Mailing Address - Zip Code:91331-2000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12411 OSBORNE ST
Practice Address - Street 2:UNIT 45
Practice Address - City:PACOIMA
Practice Address - State:CA
Practice Address - Zip Code:91331-2000
Practice Address - Country:US
Practice Address - Phone:213-435-8309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-26
Last Update Date:2016-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC9097171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist