Provider Demographics
NPI:1851582373
Name:OH, YOUNGJA (MACE)
Entity Type:Individual
Prefix:
First Name:YOUNGJA
Middle Name:
Last Name:OH
Suffix:
Gender:F
Credentials:MACE
Other - Prefix:MRS
Other - First Name:YOUNGJA
Other - Middle Name:
Other - Last Name:BANG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMFT
Mailing Address - Street 1:310 8TH ST
Mailing Address - Street 2:201
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94607-6526
Mailing Address - Country:US
Mailing Address - Phone:510-451-6792
Mailing Address - Fax:
Practice Address - Street 1:310 8TH ST
Practice Address - Street 2:201
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94607-6526
Practice Address - Country:US
Practice Address - Phone:510-451-6792
Practice Address - Fax:510-251-3860
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-08
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAL.M.F.T. 79850106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program