Provider Demographics
NPI:1326203183
Name:JUNG, JI SOO JACQUELYN (CRNP-ACUTE CARE)
Entity Type:Individual
Prefix:MS
First Name:JI SOO
Middle Name:JACQUELYN
Last Name:JUNG
Suffix:
Gender:F
Credentials:CRNP-ACUTE CARE
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:
Other - Last Name:JUNG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:401 NORTH BROADWAY
Mailing Address - Street 2:ROOM 1123
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21231-2410
Mailing Address - Country:US
Mailing Address - Phone:443-287-7990
Mailing Address - Fax:443-287-0108
Practice Address - Street 1:401 NORTH BROADWAY
Practice Address - Street 2:ROOM 1123
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21231-2410
Practice Address - Country:US
Practice Address - Phone:443-287-7990
Practice Address - Fax:443-287-0108
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-22
Last Update Date:2013-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR131208363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD062820400Medicaid