Provider Demographics
NPI:1740922293
Name:CHANG, JO WAININ
Entity type:Individual
Prefix:
First Name:JO
Middle Name:WAININ
Last Name:CHANG
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:JO
Other - Middle Name:
Other - Last Name:CHANG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DR CHANG
Mailing Address - Street 1:1091 BAY DR
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32168-7810
Mailing Address - Country:US
Mailing Address - Phone:202-669-7770
Mailing Address - Fax:
Practice Address - Street 1:1091 BAY DR
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32168-7810
Practice Address - Country:US
Practice Address - Phone:202-669-7770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-13
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP12045101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty