Provider Demographics
NPI:1558768671
Name:GONG, JINGRU (LAC)
Entity Type:Individual
Prefix:
First Name:JINGRU
Middle Name:
Last Name:GONG
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7451 WOODWARD AVE
Mailing Address - Street 2:#107
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-2665
Mailing Address - Country:US
Mailing Address - Phone:630-541-8136
Mailing Address - Fax:
Practice Address - Street 1:7451 WOODWARD AVE
Practice Address - Street 2:#107
Practice Address - City:WOODRIDGE
Practice Address - State:IL
Practice Address - Zip Code:60517-2665
Practice Address - Country:US
Practice Address - Phone:630-541-8136
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-04
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198000402171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist