Healthcare Provider Details

I. General information

NPI: 1497345334
Provider Name (Legal Business Name): JAEHO JANG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2021
Last Update Date: 01/25/2021
Certification Date: 01/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

FETZER GYM 210 SOUTH RD
CHAPEL HILL NC
27599-0001
US

IV. Provider business mailing address

1900 BAITY HILL DR. APT 110
CHAPEL HILL NC
27514
US

V. Phone/Fax

Practice location:
  • Phone: 919-843-2014
  • Fax:
Mailing address:
  • Phone: 402-657-4040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberLAT-4415
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: