Healthcare Provider Details

I. General information

NPI: 1114353455
Provider Name (Legal Business Name): JEE-EUN JENNY MOON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JENNY MOON LCSW

II. Dates (important events)

Enumeration Date: 09/18/2013
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4510 E PACIFIC COAST HWY SUITE 600
LONG BEACH CA
90804-3279
US

IV. Provider business mailing address

4510 E PACIFIC COAST HWY SUITE 600
LONG BEACH CA
90804-6914
US

V. Phone/Fax

Practice location:
  • Phone: 562-346-1143
  • Fax:
Mailing address:
  • Phone: 562-346-1143
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number77266
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: