Provider Demographics
NPI:1700339967
Name:LEE, JAEJUNG
Entity Type:Individual
Prefix:MISS
First Name:JAEJUNG
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 1:200 W 89TH ST
Mailing Address - Street 2:APT. 3W
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10024-1847
Mailing Address - Country:US
Mailing Address - Phone:714-331-7205
Mailing Address - Fax:
Practice Address - Street 1:200 TILLARY ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-3026
Practice Address - Country:US
Practice Address - Phone:718-855-7485
Practice Address - Fax:718-855-1317
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-25
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF402313363LP0808X
NY679880390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty