Provider Demographics
NPI:1124467436
Name:LEE, JONGNOK JENNIFER
Entity type:Individual
Prefix:
First Name:JONGNOK
Middle Name:JENNIFER
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 1:4759 N ASHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-3406
Mailing Address - Country:US
Mailing Address - Phone:773-808-7744
Mailing Address - Fax:
Practice Address - Street 1:4759 N ASHLAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-3406
Practice Address - Country:US
Practice Address - Phone:773-808-7744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-19
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019029485122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist