Provider Demographics
NPI:1992697379
Name:LEE, JEDA CHARLISE (LCSW-A)
Entity type:Individual
Prefix:
First Name:JEDA
Middle Name:CHARLISE
Last Name:LEE
Suffix:
Gender:F
Credentials:LCSW-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28052-4358
Mailing Address - Country:US
Mailing Address - Phone:704-874-1904
Mailing Address - Fax:
Practice Address - Street 1:1525 FALCON RD
Practice Address - Street 2:
Practice Address - City:EAST BEND
Practice Address - State:NC
Practice Address - Zip Code:27018-8439
Practice Address - Country:US
Practice Address - Phone:336-551-1140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-18
Last Update Date:2025-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0225711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical