Provider Demographics
NPI:1063803765
Name:LEE, JESSICA R (LMT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:R
Last Name:LEE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4670 RICHMOND RD
Mailing Address - Street 2:#250
Mailing Address - City:WARRENSVILLE HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44128
Mailing Address - Country:US
Mailing Address - Phone:216-378-9390
Mailing Address - Fax:216-378-1735
Practice Address - Street 1:4670 RICHMOND RD
Practice Address - Street 2:#250
Practice Address - City:WARRENSVILLE HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44128
Practice Address - Country:US
Practice Address - Phone:216-378-9390
Practice Address - Fax:216-378-1735
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-17
Last Update Date:2015-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.022046225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist