Provider Demographics
NPI:1275939597
Name:JEONG, SOOJUNG (LAC)
Entity Type:Individual
Prefix:
First Name:SOOJUNG
Middle Name:
Last Name:JEONG
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:SOO
Other - Middle Name:JUNG
Other - Last Name:JEONG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2045 S STATE COLLEGE BLVD
Mailing Address - Street 2:445
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92806-0167
Mailing Address - Country:US
Mailing Address - Phone:310-579-7774
Mailing Address - Fax:
Practice Address - Street 1:1535 S D ST
Practice Address - Street 2:STE108
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3253
Practice Address - Country:US
Practice Address - Phone:909-783-9400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-13
Last Update Date:2014-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16348171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist