Provider Demographics
NPI:1629554209
Name:KOO, JAHOON (ACNPC-AG)
Entity Type:Individual
Prefix:
First Name:JAHOON
Middle Name:
Last Name:KOO
Suffix:
Gender:M
Credentials:ACNPC-AG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12111 W BELOIT RD APT 6
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53228-1910
Mailing Address - Country:US
Mailing Address - Phone:262-709-6597
Mailing Address - Fax:
Practice Address - Street 1:1120 PINE ST
Practice Address - Street 2:
Practice Address - City:STANLEY
Practice Address - State:WI
Practice Address - Zip Code:54768-1297
Practice Address - Country:US
Practice Address - Phone:800-643-0554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-17
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIAPNP8026-33363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care