Provider Demographics
NPI:1881905693
Name:MOON, JAEHOON (LAC)
Entity type:Individual
Prefix:
First Name:JAEHOON
Middle Name:
Last Name:MOON
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7950 DUBLIN BLVD
Mailing Address - Street 2:SUITE 315-K
Mailing Address - City:DUBLIN
Mailing Address - State:CA
Mailing Address - Zip Code:94568-2929
Mailing Address - Country:US
Mailing Address - Phone:510-604-5112
Mailing Address - Fax:
Practice Address - Street 1:7950 DUBLIN BLVD
Practice Address - Street 2:SUITE 315-K
Practice Address - City:DUBLIN
Practice Address - State:CA
Practice Address - Zip Code:94568-2929
Practice Address - Country:US
Practice Address - Phone:510-604-5112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-25
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 13652171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist