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General NPI Number Information
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NPI Number | 1740884758
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Entity Type | Individual
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Provider Name | JISU LEE
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Gender | Female
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Dates
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Enumeration Date | 11/30/2020
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Last Update Date | 11/30/2020
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Provider Practice Location Address
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Address Line | 505 S PACIFIC AVE UNIT 103
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City | SAN PEDRO
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State | CA
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Zip | 90731-2656
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Country | US
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Telephone | 310-935-2182
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Fax |
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Provider Business Mailing Address
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Address Line | 719 ORANGE GROVE AVE APT 203
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City | GLENDALE
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State | CA
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Zip | 91205-1789
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Country | US
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Telephone | 626-808-7075
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171100000X
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Taxonomy Name | Acupuncturist
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License Number | AC18969
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License Number State | CA
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