Provider Demographics
NPI:1457776361
Name:JUNG, CAROLINE MARIE (LAC, MSOM)
Entity Type:Individual
Prefix:MS
First Name:CAROLINE
Middle Name:MARIE
Last Name:JUNG
Suffix:
Gender:F
Credentials:LAC, MSOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1817 W BERWYN AVE # 3
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-1005
Mailing Address - Country:US
Mailing Address - Phone:773-497-4949
Mailing Address - Fax:
Practice Address - Street 1:1817 W BERWYN AVE # 3
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-1005
Practice Address - Country:US
Practice Address - Phone:773-497-4949
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-28
Last Update Date:2014-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198.0006382083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL74-3176446OtherEIN NUMBER