1306117247 NPI number — JENNIFER IRENE LEE CST

Table of content: (NPI 1760716187)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306117247 NPI number — JENNIFER IRENE LEE CST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEE
Provider First Name:
JENNIFER
Provider Middle Name:
IRENE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CST
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MCCOLLUM
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
IRENE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
CST
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1306117247
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/29/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
309 DEER RUN DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANGER
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76266-6606
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
469-360-4775
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7110 HUNNINGTON DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANGER
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76266-7954
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
469-360-4775
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/24/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 246ZS0410X , with the licence number:  96705 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 246ZC0007X , with the licence number: 134113 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 96705 . This is a "96705" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".