MEDICARE: JAEWON LEE

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	103K00000X	Behavior Analyst
2	222Q00000X	Developmental Therapist

General Provider Information

NPI Number	:	1033695762
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAEWON LEE

Provider Business Mailing Address
First Line	:	542 AMHERST ST STE B
Second Line	:
City	:	NASHUA
State	:	NH
Zip	:	03063-1016
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5085 W PARK BLVD STE 500
Second Line	:
City	:	PLANO
State	:	TX
Zip	:	75093-2591
Country	:	US
Telephone Number	:	877-775-9860
Fax Number	:

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

Provider Enumeration Date	:	07/16/2018
Last Update Date	:	04/08/2026

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Directions to “ JAEWON LEE ” Practice Location

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