Provider Demographics
NPI:1225217508
Name:LIU, JIMMY WOON FON (LAC)
Entity Type:Individual
Prefix:MR
First Name:JIMMY
Middle Name:WOON FON
Last Name:LIU
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 1:530 E MCDOWELL RD # 107-405
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-1549
Mailing Address - Country:US
Mailing Address - Phone:480-462-1590
Mailing Address - Fax:602-715-1566
Practice Address - Street 1:5233 E SOUTHERN AVE
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-3625
Practice Address - Country:US
Practice Address - Phone:480-567-5267
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-02
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1067171100000X
CAAC12024171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZLAC-1067OtherAZ STATE BOARD LICENSE
CAAC12024OtherLICENSE