Provider Demographics
NPI:1427045145
Name:KWAK, JENNIFER SOOHYUN (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:SOOHYUN
Last Name:KWAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15040 FAIRFIELD VILLAGE SQUARE DR # 150
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:TX
Mailing Address - Zip Code:77433-5952
Mailing Address - Country:US
Mailing Address - Phone:281-304-5100
Mailing Address - Fax:
Practice Address - Street 1:15040 FAIRFIELD VILLAGE SQUARE DR
Practice Address - Street 2:SUITE 150
Practice Address - City:CYPRESS
Practice Address - State:TX
Practice Address - Zip Code:77433-5952
Practice Address - Country:US
Practice Address - Phone:281-304-5100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-29
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL4029207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX159739501Medicaid
TX00396VMedicare ID - Type Unspecified
TXH86673Medicare UPIN