Healthcare Provider Details

I. General information

NPI: 1710786652
Provider Name (Legal Business Name): JACK YEE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2025
Last Update Date: 03/12/2025
Certification Date: 03/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

73 CRYSTAL CREST LN
ST AUGUSTINE FL
32095-9049
US

IV. Provider business mailing address

73 CRYSTAL CREST LN
ST AUGUSTINE FL
32095-9049
US

V. Phone/Fax

Practice location:
  • Phone: 310-383-9195
  • Fax:
Mailing address:
  • Phone: 310-383-9195
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberNA
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: