Provider Demographics
NPI:1811325905
Name:LEE, JESIKA RENEE (LLMSW)
Entity type:Individual
Prefix:MRS
First Name:JESIKA
Middle Name:RENEE
Last Name:LEE
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:MISS
Other - First Name:JESIKA
Other - Middle Name:RENEE
Other - Last Name:OUDEMOLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:4500 N CAMPUS RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-6123
Mailing Address - Country:US
Mailing Address - Phone:989-839-6188
Mailing Address - Fax:989-839-6221
Practice Address - Street 1:4500 N CAMPUS RIDGE DR
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-6123
Practice Address - Country:US
Practice Address - Phone:989-839-6188
Practice Address - Fax:989-839-6221
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-29
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010945801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical