Basic Information
| Provider Information | |||||||||
| NPI: | 1487094694 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | |||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 725 UNIVERSITY BLVD | ||||||||
| Address2: | |||||||||
| City: | BEAVERCREEK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453242640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372457100 | ||||||||
| FaxNumber: | 9372457999 | ||||||||
| Practice Location | |||||||||
| Address1: | 725 UNIVERSITY BLVD | ||||||||
| Address2: | |||||||||
| City: | BEAVERCREEK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453242640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372457100 | ||||||||
| FaxNumber: | 9372457999 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2013 | ||||||||
| LastUpdateDate: | 05/15/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 39103 | SC | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | #ED0383A | WV | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 34.013343 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 391035 | 05 | SC | MEDICAID | 39103 | 01 | SC | SC LICENSE | OTHER |