Provider Demographics
NPI:1912948753
Name:LEE, JEANETTE J
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:J
Last Name:LEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JAE EUN
Other - Middle Name:
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:708 ZEGGERT RD
Mailing Address - Street 2:
Mailing Address - City:ENDICOTT
Mailing Address - State:NY
Mailing Address - Zip Code:13760-3851
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:229-231 STATE ST
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13901-2756
Practice Address - Country:US
Practice Address - Phone:607-778-1112
Practice Address - Fax:607-778-1164
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF320006363LC1500X
NYF401018363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0320F320006Medicaid
NY0320F320006Medicaid