Provider Demographics
NPI:1801286786
Name:BAEK, JI
Entity type:Individual
Prefix:
First Name:JI
Middle Name:
Last Name:BAEK
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 1:11427 APPLEGRATH WAY
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20876-5609
Mailing Address - Country:US
Mailing Address - Phone:703-328-1528
Mailing Address - Fax:
Practice Address - Street 1:11427 APPLEGRATH WAY
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:MD
Practice Address - Zip Code:20876-5609
Practice Address - Country:US
Practice Address - Phone:703-328-1528
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-29
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0121000170171100000X
MDU02247171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist