Provider Demographics
NPI:1104522341
Name:JEONG, STELLA J
Entity type:Individual
Prefix:
First Name:STELLA
Middle Name:J
Last Name:JEONG
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 1:1516 N BOSWORTH AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60642-2488
Mailing Address - Country:US
Mailing Address - Phone:469-328-3892
Mailing Address - Fax:
Practice Address - Street 1:1516 N BOSWORTH AVE APT 3
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-2488
Practice Address - Country:US
Practice Address - Phone:469-328-3892
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-31
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.026006261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy