Healthcare Provider Details

I. General information

NPI: 1184810707
Provider Name (Legal Business Name): JAE HWAN JUNG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2007
Last Update Date: 08/13/2025
Certification Date: 08/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 UCLA MEDICAL PLZ SUITE 755
LOS ANGELES CA
90024-6970
US

IV. Provider business mailing address

5767 W CENTURY BLVD SUITE 400
LOS ANGELES CA
90045-5631
US

V. Phone/Fax

Practice location:
  • Phone: 310-202-6204
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License NumberA91012
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberA91012
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberA91012
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: