MEDICARE: YEONHWA JEONG

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2000X	Physical Therapy Clinic/Center	040859	NY

General Provider Information

NPI Number	:	1689177479
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	YEONHWA JEONG

Provider Business Mailing Address
First Line	:	10217 64TH RD APT 1B
Second Line	:
City	:	FOREST HILLS
State	:	NY
Zip	:	11375-1533
Country	:	US
Telephone Number	:	917-831-2395
Fax Number	:

Provider Business Practice Location Address
First Line	:	10217 64TH RD APT 1B
Second Line	:
City	:	FOREST HILLS
State	:	NY
Zip	:	11375-1533
Country	:	US
Telephone Number	:	917-831-2395
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/17/2018
Last Update Date	:	03/17/2018

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