Provider Demographics
NPI:1336782267
Name:JACKSON, SEUNGMIN OH
Entity Type:Individual
Prefix:
First Name:SEUNGMIN
Middle Name:OH
Last Name:JACKSON
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 1:3727 W 6TH ST STE 402
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90020-5112
Mailing Address - Country:US
Mailing Address - Phone:213-365-7400
Mailing Address - Fax:
Practice Address - Street 1:3727 W 6TH ST STE 402
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90020-5112
Practice Address - Country:US
Practice Address - Phone:213-365-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-23
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1185701041C0700X
CA91041104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker