Provider Demographics
NPI:1396625372
Name:LEE, JAEWON
Entity type:Individual
Prefix:
First Name:JAEWON
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 1:4538 PLYMOUTH ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32205-7116
Mailing Address - Country:US
Mailing Address - Phone:904-460-6523
Mailing Address - Fax:
Practice Address - Street 1:151 COLLEGE DR
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32065-7683
Practice Address - Country:US
Practice Address - Phone:904-604-8369
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-02
Last Update Date:2025-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL43363225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist