Provider Demographics
NPI:1871051292
Name:LEE, JARED CORY
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:CORY
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 1:3950 65TH PL
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-3781
Mailing Address - Country:US
Mailing Address - Phone:707-396-8977
Mailing Address - Fax:
Practice Address - Street 1:3950 65TH PL
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-3781
Practice Address - Country:US
Practice Address - Phone:707-396-8977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-05
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program