Provider Demographics
NPI:1093243875
Name:JOO, JAE (LAC)
Entity Type:Individual
Prefix:
First Name:JAE
Middle Name:
Last Name:JOO
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:670 E COMMONWEALTH AVE STE A
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92831-4514
Mailing Address - Country:US
Mailing Address - Phone:714-886-9836
Mailing Address - Fax:
Practice Address - Street 1:670 E COMMONWEALTH AVE STE A
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92831-4514
Practice Address - Country:US
Practice Address - Phone:714-886-9836
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-24
Last Update Date:2020-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC17522171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist