Healthcare Provider Details

I. General information

NPI: 1750208708
Provider Name (Legal Business Name): JENNIFER RU DANG GUO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2026
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13215 41ST AVE APT 6D
FLUSHING NY
11355-3963
US

IV. Provider business mailing address

13215 41ST AVE APT 6D
FLUSHING NY
11355-3963
US

V. Phone/Fax

Practice location:
  • Phone: 845-490-3872
  • Fax:
Mailing address:
  • Phone: 845-490-3872
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number004645
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: