Healthcare Provider Details

I. General information

NPI: 1740787514
Provider Name (Legal Business Name): JACQUELYNN T LEE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2018
Last Update Date: 08/27/2025
Certification Date: 08/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2724 N TENAYA WAY FL 2
LAS VEGAS NV
89128-0424
US

IV. Provider business mailing address

3016 W CHARLESTON BLVD STE 100
LAS VEGAS NV
89102-1973
US

V. Phone/Fax

Practice location:
  • Phone: 702-671-5110
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number27630
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number2024013118
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License NumberBP1-0063431
License Number StateTX
# 4
Primary TaxonomyY
Taxonomy Code2082S0105X
TaxonomySurgery of the Hand (Plastic Surgery) Physician
License Number27630
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: