Provider Demographics
NPI:1174057657
Name:LEE, JONATHAN
Entity type:Individual
Prefix:
First Name:JONATHAN
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 1:1310 W A ST
Mailing Address - Street 2:102
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-4035
Mailing Address - Country:US
Mailing Address - Phone:818-331-5990
Mailing Address - Fax:
Practice Address - Street 1:1310 W A ST
Practice Address - Street 2:102
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-4035
Practice Address - Country:US
Practice Address - Phone:818-331-5990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-12
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer