Provider Demographics
NPI:1902914351
Name:LEE, JENNIFER (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3316 W 66TH ST
Mailing Address - Street 2:STE 200
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-2506
Mailing Address - Country:US
Mailing Address - Phone:952-920-3808
Mailing Address - Fax:952-920-8899
Practice Address - Street 1:3316 W 66TH ST
Practice Address - Street 2:STE 200
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2506
Practice Address - Country:US
Practice Address - Phone:952-920-3808
Practice Address - Fax:952-920-8899
Is Sole Proprietor?:No
Enumeration Date:2006-08-27
Last Update Date:2010-03-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN43535207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN717605800Medicaid
MN717605800Medicaid
MN070000716Medicare ID - Type Unspecified