Provider Demographics
NPI:1871276360
Name:LEE, JISIN
Entity type:Individual
Prefix:
First Name:JISIN
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 WYANDEMERE DR
Mailing Address - Street 2:
Mailing Address - City:WOODCLIFF LAKE
Mailing Address - State:NJ
Mailing Address - Zip Code:07677-7665
Mailing Address - Country:US
Mailing Address - Phone:201-694-9286
Mailing Address - Fax:
Practice Address - Street 1:65 N MAPLE AVE STE 202
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-3233
Practice Address - Country:US
Practice Address - Phone:201-473-2981
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-10
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL06995300104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker