Provider Demographics
NPI:1043830193
Name:LE, JIM (MD)
Entity type:Individual
Prefix:
First Name:JIM
Middle Name:
Last Name:LE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 WHITE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28540
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:PSC 561 BOX 1877
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96310-0019
Practice Address - Country:US
Practice Address - Phone:315-255-8383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-18
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171000000X
NC2021-03058208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No171000000XOther Service ProvidersMilitary Health Care Provider