Provider Demographics
NPI:1578907580
Name:WON, JI SOO
Entity Type:Individual
Prefix:
First Name:JI SOO
Middle Name:
Last Name:WON
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 1:1321 COLBY AVE
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-1665
Mailing Address - Country:US
Mailing Address - Phone:425-297-5220
Mailing Address - Fax:
Practice Address - Street 1:14442 124TH AVE NE
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-4801
Practice Address - Country:US
Practice Address - Phone:425-821-7899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-20
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAIR 60343030390200000X
WAPH607461501835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program