Healthcare Provider Details

I. General information

NPI: 1447414552
Provider Name (Legal Business Name): JUNGYEOL OH PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2008
Last Update Date: 01/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 GOODRICH BLVD
COMMERCE CA
90022-5103
US

IV. Provider business mailing address

1616 LEYCROSS DR
LA CANADA CA
91011-3010
US

V. Phone/Fax

Practice location:
  • Phone: 323-832-9795
  • Fax:
Mailing address:
  • Phone: 818-790-7881
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY15310
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number288613
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberNP18183
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: