=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801155528
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEAN SOONHA LEE L.AC.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/15/2012
-----------------------------------------------------
Last Update Date | 05/15/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 169 WYTHE AVE SUITE 104
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11249-8676
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-930-7920
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 268 FRANKLIN ST 3R
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11222-6177
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-522-8034
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | 002708
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------