Provider Demographics
NPI:1700303609
Name:LEE, JISUN
Entity Type:Individual
Prefix:
First Name:JISUN
Middle Name:
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 1:1080 S LA CIENEGA BLVD STE 208
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90035-2680
Mailing Address - Country:US
Mailing Address - Phone:213-426-6402
Mailing Address - Fax:
Practice Address - Street 1:1080 S. LA CIENEGA BLVD
Practice Address - Street 2:#208
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90035
Practice Address - Country:US
Practice Address - Phone:213-820-8783
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28062355S0801X
CA235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant