Provider Demographics
NPI:1679766125
Name:JAE MEDICAL CLINIC, LLC
Entity Type:Organization
Organization Name:JAE MEDICAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ZORAYDA
Authorized Official - Middle Name:OLAYA
Authorized Official - Last Name:DELEON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-963-5500
Mailing Address - Street 1:311 PALISADE AVE
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07307-1772
Mailing Address - Country:US
Mailing Address - Phone:201-963-5500
Mailing Address - Fax:201-963-5563
Practice Address - Street 1:311 PALISADE AVE
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07307-1772
Practice Address - Country:US
Practice Address - Phone:201-963-5500
Practice Address - Fax:201-963-5563
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-18
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA073038261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJH80480Medicare UPIN