Provider Demographics
NPI:1679703979
Name:SHIN, JAEHO (DC)
Entity Type:Individual
Prefix:
First Name:JAEHO
Middle Name:
Last Name:SHIN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41-10 163RD STREET
Mailing Address - Street 2:1ST FL
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11358
Mailing Address - Country:US
Mailing Address - Phone:917-239-2818
Mailing Address - Fax:347-732-9172
Practice Address - Street 1:41-10 163RD STREET
Practice Address - Street 2:1ST FL
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11358
Practice Address - Country:US
Practice Address - Phone:917-239-2818
Practice Address - Fax:347-732-9172
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-21
Last Update Date:2011-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX011688111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor