Healthcare Provider Details

I. General information

NPI: 1275417016
Provider Name (Legal Business Name): JING LUO
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2025
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14015B SANFORD AVE FL 2
FLUSHING NY
11355-2557
US

IV. Provider business mailing address

2810 JACKSON AVE APT 19M
LONG ISLAND CITY NY
11101-3146
US

V. Phone/Fax

Practice location:
  • Phone: 315-413-9070
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number017842
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: