Provider Demographics
NPI:1740541978
Name:SAKOUNPHONG, CHAN (MS)
Entity type:Individual
Prefix:MRS
First Name:CHAN
Middle Name:
Last Name:SAKOUNPHONG
Suffix:
Gender:F
Credentials:MS
Other - Prefix:MRS
Other - First Name:JENNY
Other - Middle Name:
Other - Last Name:SAKOUNPHONG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS
Mailing Address - Street 1:4443 E SPRING ST
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92869-3517
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4443 E SPRING ST
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92869-3517
Practice Address - Country:US
Practice Address - Phone:626-806-9101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-05
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA108717106H00000X
101YM0800X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program