Healthcare Provider Details

I. General information

NPI: 1669345542
Provider Name (Legal Business Name): JAE N/A LEE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2025
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 OLD PEACHTREE RD NW
SUWANEE GA
30024-2937
US

IV. Provider business mailing address

625 OLD PEACHTREE RD NW
SUWANEE GA
30024-2937
US

V. Phone/Fax

Practice location:
  • Phone: 678-225-7500
  • Fax:
Mailing address:
  • Phone: 678-225-7500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: