Basic Information
| Provider Information | |||||||||
| NPI: | 1205151875 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | JACOB | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11350 MCCORMICK RD EXECUTIVE PLAZA 1 | ||||||||
| Address2: | STE 501 | ||||||||
| City: | HUNT VALLEY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037384331 | ||||||||
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| Practice Location | |||||||||
| Address1: | 190 CAMPUS BLVD | ||||||||
| Address2: | SUITE 420 | ||||||||
| City: | WINCHESTER | ||||||||
| State: | VA | ||||||||
| PostalCode: | 226012872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5409310400 | ||||||||
| FaxNumber: | 5406679453 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2010 | ||||||||
| LastUpdateDate: | 07/26/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 0102204167 | VA | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 208VP0014X | H80550 | MD | Y | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
No ID Information.