Healthcare Provider Details

I. General information

NPI: 1962397422
Provider Name (Legal Business Name): JIN HO JUNG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2025
Last Update Date: 06/12/2025
Certification Date: 06/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5741 CARLTON WAY APT 317
LOS ANGELES CA
90028-6785
US

IV. Provider business mailing address

5741 CARLTON WAY APT 317
LOS ANGELES CA
90028-6785
US

V. Phone/Fax

Practice location:
  • Phone: 213-505-8680
  • Fax:
Mailing address:
  • Phone: 213-505-8680
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number53376
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: