Provider Demographics
NPI:1104171792
Name:LEE, JENNIFER GRACE WALTER (PHD)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:GRACE WALTER
Last Name:LEE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:10029 HONEY MEADOWS RD
Mailing Address - Street 2:
Mailing Address - City:MECHANICSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23116-2614
Mailing Address - Country:US
Mailing Address - Phone:260-385-1566
Mailing Address - Fax:
Practice Address - Street 1:4001 INDIAN SCHOOL RD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-3816
Practice Address - Country:US
Practice Address - Phone:505-272-6203
Practice Address - Fax:505-299-4740
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-19
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NMPSY1626103TC0700X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical