Healthcare Provider Details

I. General information

NPI: 1366366577
Provider Name (Legal Business Name): WONYOUNG JUNG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2026
Last Update Date: 08/10/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 HAVENWOOD DR
SHIRLEY NY
11967-3901
US

IV. Provider business mailing address

34 RUSH ST
PORT JEFFERSON STATION NY
11776-4018
US

V. Phone/Fax

Practice location:
  • Phone: 631-395-4108
  • Fax:
Mailing address:
  • Phone: 518-366-7119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: