Healthcare Provider Details

I. General information

NPI: 1437094521
Provider Name (Legal Business Name): JENNIFER NGOC NGUYEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2026
Last Update Date: 04/23/2026
Certification Date: 04/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

489 ATLANTIC AVE
BROOKLYN NY
11217-2985
US

IV. Provider business mailing address

2103 LANTERN LN
ORELAND PA
19075-2513
US

V. Phone/Fax

Practice location:
  • Phone: 718-332-4747
  • Fax:
Mailing address:
  • Phone: 215-740-1494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number034619-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: