Provider Demographics
NPI:1275986986
Name:CHA, JAESOON KATIE (LPN)
Entity Type:Individual
Prefix:MS
First Name:JAESOON
Middle Name:KATIE
Last Name:CHA
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:716 FULLER ST
Mailing Address - Street 2:
Mailing Address - City:FORT HUACHUCA
Mailing Address - State:AZ
Mailing Address - Zip Code:85613-1624
Mailing Address - Country:US
Mailing Address - Phone:520-533-9113
Mailing Address - Fax:520-533-5148
Practice Address - Street 1:716 FULLER ST
Practice Address - Street 2:
Practice Address - City:FORT HUACHUCA
Practice Address - State:AZ
Practice Address - Zip Code:85613-1624
Practice Address - Country:US
Practice Address - Phone:520-533-9113
Practice Address - Fax:520-533-5148
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-18
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN221010164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse