Provider Demographics
NPI:1497184055
Name:JONG, AILEEN C (LAC)
Entity type:Individual
Prefix:
First Name:AILEEN
Middle Name:C
Last Name:JONG
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10956 VIA SORRENTO
Mailing Address - Street 2:
Mailing Address - City:CUPERTINO
Mailing Address - State:CA
Mailing Address - Zip Code:95014-6313
Mailing Address - Country:US
Mailing Address - Phone:408-475-7925
Mailing Address - Fax:
Practice Address - Street 1:1002 S DE ANZA BLVD STE 4
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95129-2778
Practice Address - Country:US
Practice Address - Phone:408-475-7925
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-04
Last Update Date:2015-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC15694171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist