Healthcare Provider Details

I. General information

NPI: 1790208403
Provider Name (Legal Business Name): JESSICA S LEE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2017
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 PHILIP DR
SHELTON CT
06484-5132
US

IV. Provider business mailing address

65 PHILIP DR
SHELTON CT
06484-5132
US

V. Phone/Fax

Practice location:
  • Phone: 646-796-4675
  • Fax:
Mailing address:
  • Phone: 646-796-4675
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number2327
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: