MEDICARE: MICHELLE YUNJEE JEONG

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	183500000X	Pharmacist	051301712	IL

General Provider Information

NPI Number	:	1144793688
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE YUNJEE JEONG

Provider Business Mailing Address
First Line	:	3130 N LAKE SHORE DR APT 1602
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-4921
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4343 N KEDZIE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-1301
Country	:	US
Telephone Number	:	773-603-4419
Fax Number	:

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

Provider Enumeration Date	:	01/08/2019
Last Update Date	:	01/08/2019

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