Provider Demographics
NPI:1366093916
Name:LEE, JENNIFER CARRIE
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:CARRIE
Last Name:LEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5135 SE 41ST AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-4234
Mailing Address - Country:US
Mailing Address - Phone:509-710-9668
Mailing Address - Fax:
Practice Address - Street 1:5135 SE 41ST AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-4234
Practice Address - Country:US
Practice Address - Phone:509-710-9668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-25
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR17916225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist