Provider Demographics
NPI:1487177879
Name:JEONG, NAMSOO
Entity Type:Individual
Prefix:
First Name:NAMSOO
Middle Name:
Last Name:JEONG
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 1:623 HIGHLAND ST
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91104-1120
Mailing Address - Country:US
Mailing Address - Phone:626-808-5249
Mailing Address - Fax:
Practice Address - Street 1:722 FREMONT AVE
Practice Address - Street 2:
Practice Address - City:SOUTH PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91030-2530
Practice Address - Country:US
Practice Address - Phone:626-808-5249
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-18
Last Update Date:2017-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA100282106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist