Provider Demographics
NPI:1548771504
Name:LEE, JAE WOONG (LAC)
Entity Type:Individual
Prefix:MR
First Name:JAE WOONG
Middle Name:
Last Name:LEE
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 1:1217 16TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-1710
Mailing Address - Country:US
Mailing Address - Phone:201-921-3180
Mailing Address - Fax:
Practice Address - Street 1:14327 ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-6139
Practice Address - Country:US
Practice Address - Phone:201-921-3180
Practice Address - Fax:201-921-3180
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-17
Last Update Date:2017-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005971-1171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist