Provider Demographics
NPI:1699253237
Name:LEE, JERELYN GENTRY
Entity type:Individual
Prefix:
First Name:JERELYN
Middle Name:GENTRY
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 1:4610 E. DOUGLAS STREET
Mailing Address - Street 2:SUITE 150
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67218
Mailing Address - Country:US
Mailing Address - Phone:423-785-7841
Mailing Address - Fax:
Practice Address - Street 1:8201 QUIVIRA RD
Practice Address - Street 2:
Practice Address - City:LENEXA
Practice Address - State:KS
Practice Address - Zip Code:66215-2703
Practice Address - Country:US
Practice Address - Phone:423-756-2894
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-06
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS03880101YP2500X
MI24331131125101YP2500X
TN5915101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional