Healthcare Provider Details

I. General information

NPI: 1306462569
Provider Name (Legal Business Name): JENNY SONG MINCHEW PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNY HEE SONG

II. Dates (important events)

Enumeration Date: 06/23/2020
Last Update Date: 09/28/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48A E RIDGE PIKE
CONSHOHOCKEN PA
19428-2117
US

IV. Provider business mailing address

400 FAYETTE ST STE 180
CONSHOHOCKEN PA
19428-2186
US

V. Phone/Fax

Practice location:
  • Phone: 484-243-6735
  • Fax: 484-533-3990
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberOA006828
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA064682
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-10955
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: