Provider Demographics
NPI:1124387287
Name:CHANG, JAE YONG (LAC)
Entity Type:Individual
Prefix:MR
First Name:JAE
Middle Name:YONG
Last Name:CHANG
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2486 5TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-7840
Mailing Address - Country:US
Mailing Address - Phone:201-945-4372
Mailing Address - Fax:
Practice Address - Street 1:579 BERGEN BLVD FL 2
Practice Address - Street 2:
Practice Address - City:RIDGEFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07657-2032
Practice Address - Country:US
Practice Address - Phone:201-945-4372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-10
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MZ00030400171100000X
NY001627171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist