Provider Demographics
NPI:1982792362
Name:JUNG, KOOYEOLL (LAC)
Entity Type:Individual
Prefix:MR
First Name:KOOYEOLL
Middle Name:
Last Name:JUNG
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:MR
Other - First Name:ERIC
Other - Middle Name:K
Other - Last Name:JUNG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LAC
Mailing Address - Street 1:11516 SE MILL PLAIN BLVD STE 2K
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-5082
Mailing Address - Country:US
Mailing Address - Phone:360-885-3395
Mailing Address - Fax:360-885-3453
Practice Address - Street 1:11516 SE MILL PLAIN BLVD STE 2K
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-5082
Practice Address - Country:US
Practice Address - Phone:360-885-3395
Practice Address - Fax:360-885-3453
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAC00000658171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist