Provider Demographics
NPI:1386067155
Name:LEE, JAE S (LAC, LMT)
Entity type:Individual
Prefix:MR
First Name:JAE
Middle Name:S
Last Name:LEE
Suffix:
Gender:M
Credentials:LAC, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14748 ROOSEVELT AVE APT 1F
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-4709
Mailing Address - Country:US
Mailing Address - Phone:407-730-1128
Mailing Address - Fax:
Practice Address - Street 1:14748 ROOSEVELT AVE APT 1F
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-4709
Practice Address - Country:US
Practice Address - Phone:407-730-1128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-29
Last Update Date:2014-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005243171100000X
NY026797225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist