Provider Demographics
NPI:1184053662
Name:CHUNG, JAE HWAN (NP)
Entity type:Individual
Prefix:MR
First Name:JAE
Middle Name:HWAN
Last Name:CHUNG
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 MISSION ST APT 5
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-3329
Mailing Address - Country:US
Mailing Address - Phone:310-850-9925
Mailing Address - Fax:
Practice Address - Street 1:520 S VIRGIL AVE STE 507
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90020-1452
Practice Address - Country:US
Practice Address - Phone:310-850-9925
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-05
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95004056363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily