Provider Demographics
NPI:1437877362
Name:LEE JACKSON ENTERPRISES
Entity type:Organization
Organization Name:LEE JACKSON ENTERPRISES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:NIKIA
Authorized Official - Middle Name:
Authorized Official - Last Name:AUTRY
Authorized Official - Suffix:
Authorized Official - Credentials:NIKIA A AUTRY
Authorized Official - Phone:866-301-1456
Mailing Address - Street 1:3626 N HALL ST STE 610
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75219-5131
Mailing Address - Country:US
Mailing Address - Phone:866-301-1456
Mailing Address - Fax:469-898-6344
Practice Address - Street 1:3626 N HALL ST STE 610
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75219-5131
Practice Address - Country:US
Practice Address - Phone:866-301-1456
Practice Address - Fax:469-898-6344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-17
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomyGroup - Multi-Specialty
No1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Multi-Specialty
No224900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMastectomy FitterGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty