Basic Information
| Provider Information | |||||||||
| NPI: | 1760788731 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SO | ||||||||
| FirstName: | JENNY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1518 10TH AVE | ||||||||
| Address2: | APT A | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6469121167 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 142 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | DANVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 24541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4347992225 | ||||||||
| FaxNumber: | 4347737924 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2011 | ||||||||
| LastUpdateDate: | 10/11/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | C1-0012038 | DE | N | Allopathic & Osteopathic Physicians | Hospitalist | 208M00000X | ME121925 | FL | N | Allopathic & Osteopathic Physicians | Hospitalist | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208M00000X | 0101254671 | VA | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 0101254671 | 01 | VA | LICENSE | OTHER |