Healthcare Provider Details

I. General information

NPI: 1366320970
Provider Name (Legal Business Name): DASEULI JEONG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2025
Last Update Date: 09/15/2025
Certification Date: 09/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3903 FAIR RIDGE DR STE 209
FAIRFAX VA
22033-2944
US

IV. Provider business mailing address

3903 FAIR RIDGE DR STE 209
FAIRFAX VA
22033-2944
US

V. Phone/Fax

Practice location:
  • Phone: 703-865-6490
  • Fax:
Mailing address:
  • Phone: 703-865-6490
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QB0002X
TaxonomyObesity Medicine (Family Medicine) Physician
License Number0024194635
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: