Provider Demographics
NPI:1881027506
Name:BAE, PEARL JINJU (LAC)
Entity Type:Individual
Prefix:
First Name:PEARL
Middle Name:JINJU
Last Name:BAE
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 1:60 PARK PL STE 504
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07102-5513
Mailing Address - Country:US
Mailing Address - Phone:973-803-8130
Mailing Address - Fax:
Practice Address - Street 1:60 PARK PL STE 504
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07102-5513
Practice Address - Country:US
Practice Address - Phone:973-803-8130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-16
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004823171100000X
NJ25MZ00097300171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist