Provider Demographics
NPI:1922334739
Name:JEON, CHANG HOON (MSOM, MPH, DHS, PHD)
Entity Type:Individual
Prefix:DR
First Name:CHANG HOON
Middle Name:
Last Name:JEON
Suffix:
Gender:M
Credentials:MSOM, MPH, DHS, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2235 S BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-4617
Mailing Address - Country:US
Mailing Address - Phone:208-901-1956
Mailing Address - Fax:
Practice Address - Street 1:2235 S. BROADWAY AVE.
Practice Address - Street 2:190
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706
Practice Address - Country:US
Practice Address - Phone:208-901-1956
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-29
Last Update Date:2012-03-16
Deactivation Date:2012-01-26
Deactivation Code:
Reactivation Date:2012-03-16
Provider Licenses
StateLicense IDTaxonomies
IDACU-276171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist