Provider Demographics
NPI:1639525751
Name:JEON, ANDREW
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:JEON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9600 VETERANS DR SW # 1A116MHC
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98493-0003
Mailing Address - Country:US
Mailing Address - Phone:253-583-2729
Mailing Address - Fax:
Practice Address - Street 1:9600 VETERANS DR SW # 1A116MHC
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98493-3786
Practice Address - Country:US
Practice Address - Phone:253-583-2729
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-07
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IA105211103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program