Provider Demographics
NPI:1427483908
Name:LEE, JENIE CHUNG (OD)
Entity type:Individual
Prefix:MRS
First Name:JENIE
Middle Name:CHUNG
Last Name:LEE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:722 DEL MONTE AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94080-2230
Mailing Address - Country:US
Mailing Address - Phone:626-201-2594
Mailing Address - Fax:
Practice Address - Street 1:53 COLMA BLVD
Practice Address - Street 2:
Practice Address - City:COLMA
Practice Address - State:CA
Practice Address - Zip Code:94014-3231
Practice Address - Country:US
Practice Address - Phone:650-992-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-04
Last Update Date:2013-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14679152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist