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NPI Code Detail

MEDICARE: JAE WON LEE

MEDICARE: JAE WON 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
1390200000XStudent in an Organized Health Care Education/Training Program

General Provider Information

NPI Number : 1902748783
Entity Type Code : Individual
Provider Name (Legal Business Name) : JAE WON LEE
Provider Business Mailing Address
First Line : 6216 BROOKRIDGE DR
Second Line :
City : FLOWERY BRANCH
State : GA
Zip : 30542-5378
Country : US
Telephone Number : 678-617-6605
Fax Number :
Provider Business Practice Location Address
First Line : 417 W 3RD AVE
Second Line :
City : ALBANY
State : GA
Zip : 31701-1943
Country : US
Telephone Number : 229-312-1000
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/08/2026
Last Update Date : 04/08/2026

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