Provider Demographics
NPI:1376237008
Name:KO, EUNJEONG
Entity Type:Individual
Prefix:
First Name:EUNJEONG
Middle Name:
Last Name:KO
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 1:4725 SHEBOYGAN AVE APT 125
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705-3152
Mailing Address - Country:US
Mailing Address - Phone:608-999-0476
Mailing Address - Fax:
Practice Address - Street 1:802 E GORHAM ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53703-1524
Practice Address - Country:US
Practice Address - Phone:608-999-0476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-06
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health