Healthcare Provider Details

I. General information

NPI: 1730076514
Provider Name (Legal Business Name): JENNIFER SHERESE LEE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2025
Last Update Date: 08/13/2025
Certification Date: 06/23/2025
Deactivation Date: 06/23/2025
Reactivation Date: 08/13/2025

III. Provider practice location address

618 S WISCONSIN AVE APT D
ADDISON IL
60101-4716
US

IV. Provider business mailing address

618 S WISCONSIN AVE APT D618S
ADDISON IL
60101-4716
US

V. Phone/Fax

Practice location:
  • Phone: 331-290-4975
  • Fax:
Mailing address:
  • Phone: 331-290-4975
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: