Provider Demographics
NPI:1780248062
Name:LEE, JESSE
Entity type:Individual
Prefix:MR
First Name:JESSE
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2230 LYNN RD STE 103
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360-1958
Mailing Address - Country:US
Mailing Address - Phone:805-495-5113
Mailing Address - Fax:805-496-2861
Practice Address - Street 1:2230 LYNN RD STE 103
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-1958
Practice Address - Country:US
Practice Address - Phone:805-495-5113
Practice Address - Fax:805-496-2861
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-23
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist