Provider Demographics
NPI:1831757491
Name:KANG-SUH, JEANNIE
Entity type:Individual
Prefix:
First Name:JEANNIE
Middle Name:
Last Name:KANG-SUH
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 1:236 KENILWORTH RD
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-5209
Mailing Address - Country:US
Mailing Address - Phone:201-615-9563
Mailing Address - Fax:
Practice Address - Street 1:17-07 ROMAINE ST
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-2150
Practice Address - Country:US
Practice Address - Phone:201-794-6573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-30
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00304400101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional