MEDICARE: JENNIFER SOYOUNG LEE RPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	019601	NY
2	225100000X	Physical Therapist	40QA01076000	NJ

General Provider Information

NPI Number	:	1023298411
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER SOYOUNG LEE RPT

Provider Business Mailing Address
First Line	:	1608 LEMOINE AVE STE 202
Second Line	:
City	:	FORT LEE
State	:	NJ
Zip	:	07024-5636
Country	:	US
Telephone Number	:	201-894-5452
Fax Number	:	201-334-0068

Provider Business Practice Location Address
First Line	:	1608 LEMOINE AVE STE 202
Second Line	:
City	:	FORT LEE
State	:	NJ
Zip	:	07024-5636
Country	:	US
Telephone Number	:	201-894-5452
Fax Number	:	201-334-0068

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/14/2007
Last Update Date	:	01/06/2022

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