Provider Demographics
NPI:1386194835
Name:LEE, JILLIAN
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
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 1:2436 BARCLAY ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21218-5326
Mailing Address - Country:US
Mailing Address - Phone:443-939-5522
Mailing Address - Fax:
Practice Address - Street 1:8353 TX-34
Practice Address - Street 2:
Practice Address - City:WOLFE CITY
Practice Address - State:TX
Practice Address - Zip Code:75496
Practice Address - Country:US
Practice Address - Phone:443-939-5522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-08
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer