Provider Demographics
NPI:1770384448
Name:JEONG, HANNA
Entity type:Individual
Prefix:
First Name:HANNA
Middle Name:
Last Name:JEONG
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5316 OUTLOOK BLVD UNIT 205
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-1496
Mailing Address - Country:US
Mailing Address - Phone:857-364-1485
Mailing Address - Fax:
Practice Address - Street 1:1601 W US HIGHWAY 50
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-1690
Practice Address - Country:US
Practice Address - Phone:857-364-1485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-20
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0025123183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist