Healthcare Provider Details

I. General information

NPI: 1497901284
Provider Name (Legal Business Name): JENEE S LEE OD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2008
Last Update Date: 08/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4637 PINE VALLEY CIR
STOCKTON CA
95219-1876
US

IV. Provider business mailing address

1616 E HAMMER LN
STOCKTON CA
95210-4119
US

V. Phone/Fax

Practice location:
  • Phone: 209-479-9811
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number13397T
License Number StateCA

VIII. Authorized Official

Name: JENEE S LEE
Title or Position: OPTOMETRIST
Credential: OD
Phone: 209-479-9811