Provider Demographics
NPI:1326820770
Name:KONG, JIWON
Entity Type:Individual
Prefix:
First Name:JIWON
Middle Name:
Last Name:KONG
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 1:500 WINDSOR DR APT 304
Mailing Address - Street 2:
Mailing Address - City:PALISADES PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07650-2344
Mailing Address - Country:US
Mailing Address - Phone:201-401-4171
Mailing Address - Fax:
Practice Address - Street 1:38 W 32ND ST STE 1300
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-3877
Practice Address - Country:US
Practice Address - Phone:212-760-7575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-19
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007144171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist