Provider Demographics
NPI:1124195862
Name:YOO, JAESUN (LIC AC)
Entity Type:Individual
Prefix:
First Name:JAESUN
Middle Name:
Last Name:YOO
Suffix:
Gender:F
Credentials:LIC AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 MAMARONECK AVE STE 414
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:NY
Mailing Address - Zip Code:10528-2430
Mailing Address - Country:US
Mailing Address - Phone:914-421-1001
Mailing Address - Fax:914-421-1001
Practice Address - Street 1:450 MAMARONECK AVE STE 414
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:NY
Practice Address - Zip Code:10528
Practice Address - Country:US
Practice Address - Phone:914-421-1001
Practice Address - Fax:914-421-1001
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA230147171100000X
NY003396171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist