Provider Demographics
NPI:1982159349
Name:NAM, JI YUN
Entity Type:Individual
Prefix:
First Name:JI YUN
Middle Name:
Last Name:NAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JIYUN
Other - Middle Name:
Other - Last Name:NAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2081 PALOS VERDES DR N
Mailing Address - Street 2:
Mailing Address - City:LOMITA
Mailing Address - State:CA
Mailing Address - Zip Code:90717-3701
Mailing Address - Country:US
Mailing Address - Phone:310-325-6542
Mailing Address - Fax:
Practice Address - Street 1:2081 PALOS VERDES DR N
Practice Address - Street 2:
Practice Address - City:LOMITA
Practice Address - State:CA
Practice Address - Zip Code:90717-3701
Practice Address - Country:US
Practice Address - Phone:310-325-6542
Practice Address - Fax:310-534-6045
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-16
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31479103TC0700X
225400000X, 225C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation CounselorGroup - Single Specialty