Provider Demographics
NPI:1831458322
Name:JUNN, JACQUELINE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:JUNN
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 1:1364 CLIFTON RD NE BG20
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30332-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:40 SUNSHINE COTTAGE RD
Practice Address - Street 2:
Practice Address - City:VALHALLA
Practice Address - State:NY
Practice Address - Zip Code:10595-1524
Practice Address - Country:US
Practice Address - Phone:914-594-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-03
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1535902085R0202X
NY390200000X
GA948622085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program