Healthcare Provider Details

I. General information

NPI: 1699858464
Provider Name (Legal Business Name): TODD MICHAEL JUNGKUNTZ PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 06/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4929 WILSHIRE BLVD SUITE 510
LOS ANGELES CA
90010-3808
US

IV. Provider business mailing address

451 S MAIN ST #1108
LOS ANGELES CA
90013-1338
US

V. Phone/Fax

Practice location:
  • Phone: 562-904-3999
  • Fax: 855-688-6746
Mailing address:
  • Phone: 310-987-8526
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY26199
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: