Healthcare Provider Details

I. General information

NPI: 1598312522
Provider Name (Legal Business Name): JEROME BOONSONG RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2019
Last Update Date: 08/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7500 HELLMAN AVE
ROSEMEAD CA
91770-2216
US

IV. Provider business mailing address

2430 S MARCELLA AVE
WEST COVINA CA
91792-2227
US

V. Phone/Fax

Practice location:
  • Phone: 626-288-1160
  • Fax: 626-371-1329
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number688333
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: