Provider Demographics
NPI:1346604394
Name:LEE, JENNIFER LYNN (DO)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:LEE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 5TH ST UNIT 548
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94710-1880
Mailing Address - Country:US
Mailing Address - Phone:909-576-8825
Mailing Address - Fax:
Practice Address - Street 1:2621 10TH ST
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94710-2674
Practice Address - Country:US
Practice Address - Phone:510-418-4079
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-06
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS019913207Q00000X
CA20A22283207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine