Healthcare Provider Details

I. General information

NPI: 1104619345
Provider Name (Legal Business Name): JANE LEE
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2025
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3880 S BASCOM AVE STE 216
SAN JOSE CA
95124-2675
US

IV. Provider business mailing address

2155 VERDUGO BLVD BOX #2100
MONTROSE CA
91020
US

V. Phone/Fax

Practice location:
  • Phone: 530-290-1630
  • Fax:
Mailing address:
  • Phone: 818-336-1080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number23017
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: