Provider Demographics
NPI:1831425354
Name:LEE, JESSICA B (DPT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:B
Last Name:LEE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:L
Other - Last Name:BUSI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:4940 VAN NUYS BLVD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-1700
Mailing Address - Country:US
Mailing Address - Phone:818-907-0952
Mailing Address - Fax:818-990-9449
Practice Address - Street 1:4940 VAN NUYS BLVD
Practice Address - Street 2:SUITE 301
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-1700
Practice Address - Country:US
Practice Address - Phone:818-907-0952
Practice Address - Fax:818-990-9449
Is Sole Proprietor?:No
Enumeration Date:2009-10-19
Last Update Date:2014-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD23075225100000X
CA41325225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC167242ZFPZMedicare PIN
MD170996ZFP1Medicare PIN