Healthcare Provider Details

I. General information

NPI: 1962882977
Provider Name (Legal Business Name): JERRED LEE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2015
Last Update Date: 06/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

62 ABMC BLDG 620305 8TH STREET
CAMP PENDLETON CA
92055
US

IV. Provider business mailing address

24474 WESTHAVEN CT
MURRIETA CA
92562-3838
US

V. Phone/Fax

Practice location:
  • Phone: 760-725-7918
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: