Healthcare Provider Details

I. General information

NPI: 1184216848
Provider Name (Legal Business Name): JEFFREY JINO JEONG O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2021
Last Update Date: 08/04/2025
Certification Date: 08/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E CALIFORNIA BLVD
PASADENA CA
91105-3205
US

IV. Provider business mailing address

100 E CALIFORNIA BLVD
PASADENA CA
91105-3205
US

V. Phone/Fax

Practice location:
  • Phone: 626-269-5348
  • Fax: 844-897-3788
Mailing address:
  • Phone: 626-269-5348
  • Fax: 844-897-3788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number10183TG
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number10183T
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT36084-TLG
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: