MEDICARE: KENDRA GRAY LEE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1275021651
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENDRA GRAY LEE

Provider Business Mailing Address
First Line	:	4427 EMERSON ST
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32207-4969
Country	:	US
Telephone Number	:	904-398-7015
Fax Number	:	904-346-0837

Provider Business Practice Location Address
First Line	:	4427 EMERSON ST
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32207-4969
Country	:	US
Telephone Number	:	904-398-7015
Fax Number	:	904-346-0837

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/01/2018
Last Update Date	:	05/01/2018

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Directions to “ KENDRA GRAY LEE ” Practice Location

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