Healthcare Provider Details

I. General information

NPI: 1720556194
Provider Name (Legal Business Name): JACOB LEE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/05/2018
Last Update Date: 01/11/2023
Certification Date: 01/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 N MARYLAND PKWY
LAS VEGAS NV
89101-3133
US

IV. Provider business mailing address

5575 S DURANGO DR STE 102
LAS VEGAS NV
89113-1834
US

V. Phone/Fax

Practice location:
  • Phone: 702-265-8436
  • Fax:
Mailing address:
  • Phone: 702-209-3544
  • Fax: 725-205-3800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberLBA0682
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: