Healthcare Provider Details

I. General information

NPI: 1073434809
Provider Name (Legal Business Name): MR. JAE CHONG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2026
Last Update Date: 07/25/2026
Certification Date: 07/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4996 LA SIERRA AVE
RIVERSIDE CA
92505-2612
US

IV. Provider business mailing address

11409 GARCIA CT
NORWALK CA
90650-5701
US

V. Phone/Fax

Practice location:
  • Phone: 951-525-3752
  • Fax:
Mailing address:
  • Phone: 951-754-6554
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: