Provider Demographics
NPI:1104243260
Name:LEE, JACOB (LAC)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:827 N BLOODWORTH ST STE A
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27604-1231
Mailing Address - Country:US
Mailing Address - Phone:919-283-8784
Mailing Address - Fax:855-854-7098
Practice Address - Street 1:827 N BLOODWORTH ST STE A
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27604-1231
Practice Address - Country:US
Practice Address - Phone:919-283-8784
Practice Address - Fax:855-854-7098
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-26
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC378171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist