Healthcare Provider Details

I. General information

NPI: 1245828946
Provider Name (Legal Business Name): MR. JEA YOO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2021
Last Update Date: 01/09/2025
Certification Date: 01/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 W LA VETA AVE STE 111
ORANGE CA
92868-4447
US

IV. Provider business mailing address

23629 GOLDEN SPRINGS DR UNIT 3H
DIAMOND BAR CA
91765-2162
US

V. Phone/Fax

Practice location:
  • Phone: 714-545-5550
  • Fax:
Mailing address:
  • Phone: 909-973-9599
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number59208
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: