MEDICARE: MR. TODD MICHAEL JUNGKUNTZ PSYD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PSY26199	CA

General Provider Information

NPI Number	:	1699858464
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TODD MICHAEL JUNGKUNTZ PSYD

Provider Business Mailing Address
First Line	:	451 S MAIN ST
Second Line	:	#1108
City	:	LOS ANGELES
State	:	CA
Zip	:	90013-1338
Country	:	US
Telephone Number	:	310-987-8526
Fax Number	:

Provider Business Practice Location Address
First Line	:	4929 WILSHIRE BLVD
Second Line	:	SUITE 510
City	:	LOS ANGELES
State	:	CA
Zip	:	90010-3808
Country	:	US
Telephone Number	:	562-904-3999
Fax Number	:	855-688-6746

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/23/2006
Last Update Date	:	06/03/2014

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