=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629090048
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEANETTE LEE O.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2006
-----------------------------------------------------
Last Update Date | 01/30/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2555 N 1ST ST
-----------------------------------------------------
City | SAN JOSE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95131-1003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-433-0800
-----------------------------------------------------
Fax | 408-577-0849
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2555 N 1ST ST
-----------------------------------------------------
City | SAN JOSE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95131-1003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-433-0800
-----------------------------------------------------
Fax | 408-577-0849
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 10538T
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------