Provider Demographics
NPI:1699858464
Name:JUNGKUNTZ, TODD MICHAEL (PSYD)
Entity Type:Individual
Prefix:MR
First Name:TODD
Middle Name:MICHAEL
Last Name:JUNGKUNTZ
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:451 S MAIN ST
Mailing Address - Street 2:#1108
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90013-1338
Mailing Address - Country:US
Mailing Address - Phone:310-987-8526
Mailing Address - Fax:
Practice Address - Street 1:4929 WILSHIRE BLVD
Practice Address - Street 2:SUITE 510
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010-3808
Practice Address - Country:US
Practice Address - Phone:562-904-3999
Practice Address - Fax:855-688-6746
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY26199103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical