Provider Demographics
NPI:1982939195
Name:JEONG, JAE YEON (PHD)
Entity Type:Individual
Prefix:DR
First Name:JAE YEON
Middle Name:
Last Name:JEONG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 N GREENE STREET
Mailing Address - Street 2:VA MARYLAND HEALTH CARE SYSTEM
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-1524
Mailing Address - Country:US
Mailing Address - Phone:410-605-7000
Mailing Address - Fax:
Practice Address - Street 1:10 N GREENE STREET
Practice Address - Street 2:VA MARYLAND HEALTH CARE SYSTEM
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1524
Practice Address - Country:US
Practice Address - Phone:410-605-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-05
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018728103T00000X
MD04731103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist