Provider Demographics
NPI:1306117247
Name:LEE, JENNIFER IRENE (CST)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:IRENE
Last Name:LEE
Suffix:
Gender:F
Credentials:CST
Other - Prefix:MISS
Other - First Name:JENNIFER
Other - Middle Name:IRENE
Other - Last Name:MCCOLLUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CST
Mailing Address - Street 1:309 DEER RUN DR
Mailing Address - Street 2:
Mailing Address - City:SANGER
Mailing Address - State:TX
Mailing Address - Zip Code:76266-6606
Mailing Address - Country:US
Mailing Address - Phone:469-360-4775
Mailing Address - Fax:
Practice Address - Street 1:7110 HUNNINGTON DR
Practice Address - Street 2:
Practice Address - City:SANGER
Practice Address - State:TX
Practice Address - Zip Code:76266-7954
Practice Address - Country:US
Practice Address - Phone:469-360-4775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-24
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX96705246ZS0410X
TX134113246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
No246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX96705Other96705