Healthcare Provider Details

I. General information

NPI: 1346807831
Provider Name (Legal Business Name): MARY JIN LU
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2019
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12912 BROOKHURST ST STE 480
GARDEN GROVE CA
92840-4867
US

IV. Provider business mailing address

12966 EUCLID ST STE 495
GARDEN GROVE CA
92840-9209
US

V. Phone/Fax

Practice location:
  • Phone: 714-636-6286
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number131766
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: