Provider Demographics
NPI:1962832113
Name:YOO, JEENAH
Entity Type:Individual
Prefix:
First Name:JEENAH
Middle Name:
Last Name:YOO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13209 NW FINDLEY ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-4553
Mailing Address - Country:US
Mailing Address - Phone:503-860-3449
Mailing Address - Fax:
Practice Address - Street 1:12596 SE STARK ST BLDG N
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233
Practice Address - Country:US
Practice Address - Phone:503-252-9657
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-24
Last Update Date:2018-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE604099471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice