Healthcare Provider Details

I. General information

NPI: 1386194835
Provider Name (Legal Business Name): JILLIAN LEE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2016
Last Update Date: 08/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8353 TX-34
WOLFE CITY TX
75496
US

IV. Provider business mailing address

2436 BARCLAY ST
BALTIMORE MD
21218-5326
US

V. Phone/Fax

Practice location:
  • Phone: 443-939-5522
  • Fax:
Mailing address:
  • Phone: 443-939-5522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: