Provider Demographics
NPI:1902147499
Name:AHN, JAECHOL (PT, LAC)
Entity Type:Individual
Prefix:MR
First Name:JAECHOL
Middle Name:
Last Name:AHN
Suffix:
Gender:M
Credentials:PT, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3409 MURRAY ST FL 2
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-3948
Mailing Address - Country:US
Mailing Address - Phone:718-888-1704
Mailing Address - Fax:718-961-2459
Practice Address - Street 1:8523 BROADWAY UNIT D
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-5866
Practice Address - Country:US
Practice Address - Phone:718-873-2303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-07
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006977171100000X
NY031899225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty