Basic Information
| Provider Information | |||||||||
| NPI: | 1548997612 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHO | ||||||||
| FirstName: | JAEKYUNG | ||||||||
| MiddleName: | JACEY | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4111 FRANKLIN ST | ||||||||
| Address2: | |||||||||
| City: | MICHIGAN CITY | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463607803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198795400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3283 WILLOWCREEK RD | ||||||||
| Address2: | |||||||||
| City: | PORTAGE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463685054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2197648439 | ||||||||
| FaxNumber: | 2197948463 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2022 | ||||||||
| LastUpdateDate: | 09/15/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 28258410A | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 71012901A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | MC7407578 | 01 | DEA NUMBER | OTHER |