Provider Demographics
NPI:1083004436
Name:OH, JENNIFER (LAC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:OH
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:579 W 215TH ST
Mailing Address - Street 2:9D
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10034-1236
Mailing Address - Country:US
Mailing Address - Phone:917-816-3019
Mailing Address - Fax:
Practice Address - Street 1:5030 BROADWAY
Practice Address - Street 2:SUITE 663
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10034-1609
Practice Address - Country:US
Practice Address - Phone:917-816-3019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-23
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005352171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist