Provider Demographics
NPI:1003435868
Name:PHAN, JUN (RDN,LDN)
Entity Type:Individual
Prefix:MISS
First Name:JUN
Middle Name:
Last Name:PHAN
Suffix:
Gender:F
Credentials:RDN,LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 W IRVING PARK RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-3077
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:850 W IRVING PARK RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-3077
Practice Address - Country:US
Practice Address - Phone:773-975-6802
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-13
Last Update Date:2020-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164007244133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered