Provider Demographics
NPI:1447673751
Name:LEE, JACK JENCHIEH
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:JENCHIEH
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 1:2900 S PACIFIC AVE
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85365-3500
Mailing Address - Country:US
Mailing Address - Phone:928-341-1288
Mailing Address - Fax:928-341-0546
Practice Address - Street 1:2900 S PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85365-3500
Practice Address - Country:US
Practice Address - Phone:928-341-1288
Practice Address - Fax:928-341-0546
Is Sole Proprietor?:No
Enumeration Date:2014-01-23
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS015990183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist