Provider Demographics
NPI:1477178937
Name:YI, JEAN JUNGMI
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:JUNGMI
Last Name:YI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18726 S WESTERN AVE STE 408
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90248-3858
Mailing Address - Country:US
Mailing Address - Phone:310-856-0800
Mailing Address - Fax:
Practice Address - Street 1:12746 CIMARRON PATH STE 103C
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78249-3420
Practice Address - Country:US
Practice Address - Phone:718-316-5358
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-10
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
TXRBT-20-111754106S00000X
TX1-22-59366103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician