Provider Demographics
NPI:1154126449
Name:HEO, JIYOUNG
Entity type:Individual
Prefix:
First Name:JIYOUNG
Middle Name:
Last Name:HEO
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3830 215TH PL
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-2312
Mailing Address - Country:US
Mailing Address - Phone:917-239-7359
Mailing Address - Fax:
Practice Address - Street 1:3830 215TH PL
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-2312
Practice Address - Country:US
Practice Address - Phone:917-239-7359
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-19
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY053694225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty