Provider Demographics
NPI:1033550017
Name:JOO, JEANNIE S
Entity Type:Individual
Prefix:
First Name:JEANNIE
Middle Name:S
Last Name:JOO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 BROAD AVE
Mailing Address - Street 2:SUITE N4
Mailing Address - City:PALISADES PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07650-2717
Mailing Address - Country:US
Mailing Address - Phone:201-945-7222
Mailing Address - Fax:201-945-7222
Practice Address - Street 1:118 BROAD AVE
Practice Address - Street 2:SUITE N4
Practice Address - City:PALISADES PARK
Practice Address - State:NJ
Practice Address - Zip Code:07650-2717
Practice Address - Country:US
Practice Address - Phone:201-945-7222
Practice Address - Fax:201-945-7222
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-08
Last Update Date:2013-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RJ006121835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ28RJ00612OtherLICENSE
NJ28RS00398200OtherLICENSE