Provider Demographics
NPI:1548676000
Name:JOE, JALYOUNG
Entity type:Individual
Prefix:
First Name:JALYOUNG
Middle Name:
Last Name:JOE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 BROOKLINE AVE # BAKER5
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-5491
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:330 BROOKLINE AVE # BAKER5
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215
Practice Address - Country:US
Practice Address - Phone:617-632-8930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-06
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT205945207R00000X
PAMD4637342084N0400X
MA2743482084N0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology