Provider Demographics
NPI:1023373685
Name:AHN, JONGKOO (LAC,LMT)
Entity type:Individual
Prefix:
First Name:JONGKOO
Middle Name:
Last Name:AHN
Suffix:
Gender:M
Credentials:LAC,LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 HALLOCK RD STE 6A
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-3077
Mailing Address - Country:US
Mailing Address - Phone:917-563-1824
Mailing Address - Fax:929-900-1843
Practice Address - Street 1:215 HALLOCK RD STE 6A
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790
Practice Address - Country:US
Practice Address - Phone:917-563-1824
Practice Address - Fax:929-900-1843
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-10
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025164225700000X
NY003747171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty