Provider Demographics
NPI:1982480075
Name:HA, JAE BUM
Entity Type:Individual
Prefix:
First Name:JAE
Middle Name:BUM
Last Name:HA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5220 N O CONNOR BLVD STE 106
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75039-5738
Mailing Address - Country:US
Mailing Address - Phone:972-742-3913
Mailing Address - Fax:
Practice Address - Street 1:2216 ROYAL LN STE 113
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75229-7802
Practice Address - Country:US
Practice Address - Phone:972-742-3913
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-05
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14810111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor