Provider Demographics
NPI:1891934030
Name:JANG, JAE SOO (AC)
Entity Type:Individual
Prefix:DR
First Name:JAE
Middle Name:SOO
Last Name:JANG
Suffix:
Gender:M
Credentials:AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3750 W 6TH ST STE 103
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90020-5106
Mailing Address - Country:US
Mailing Address - Phone:213-219-2739
Mailing Address - Fax:213-381-7575
Practice Address - Street 1:3750 W 6TH ST STE 103
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90020-5106
Practice Address - Country:US
Practice Address - Phone:213-219-2739
Practice Address - Fax:213-381-7575
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-11
Last Update Date:2009-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC12154171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist