Provider Demographics
NPI:1770937641
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:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:365 HAWTHORNE AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-3115
Mailing Address - Country:US
Mailing Address - Phone:510-465-5523
Mailing Address - Fax:510-832-6061
Practice Address - Street 1:365 HAWTHORNE AVE STE 101
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3115
Practice Address - Country:US
Practice Address - Phone:510-465-5523
Practice Address - Fax:510-832-6061
Is Sole Proprietor?:No
Enumeration Date:2016-04-18
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA153111208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program