Provider Demographics
NPI:1841862281
Name:JUNG, ALYSSA JAE YOUN
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:JAE YOUN
Last Name:JUNG
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 1:508 PORTER ST APT 8
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205-1958
Mailing Address - Country:US
Mailing Address - Phone:818-926-8896
Mailing Address - Fax:
Practice Address - Street 1:508 PORTER ST APT 8
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205-1958
Practice Address - Country:US
Practice Address - Phone:818-926-8896
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-14
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA451406225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA98555773DOtherLA CARE PLAN