Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XM0800X | Mental Health | 12293 | CA |
NPI | 1629325808 |
---|---|
Provider Name | Jennifer Lee |
First Address | San Pedro, CA 90731-3320 |
Second Address | San Pedro, CA 90731-3320 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 07/08/2012 |
Last Update Date | 07/08/2012 |