Provider Demographics
NPI:1164140109
Name:CHUN, JACKY KIM (PA-C)
Entity Type:Individual
Prefix:
First Name:JACKY
Middle Name:KIM
Last Name:CHUN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12125 CYPRESS SPRING RD
Mailing Address - Street 2:
Mailing Address - City:CLARKSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20871-4465
Mailing Address - Country:US
Mailing Address - Phone:808-728-8465
Mailing Address - Fax:
Practice Address - Street 1:8600 OLD GEORGETOWN RD
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20814-1422
Practice Address - Country:US
Practice Address - Phone:301-896-3100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-16
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0008525363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical