Healthcare Provider Details

I. General information

NPI: 1730681578
Provider Name (Legal Business Name): JAE HOON SONG M.ED, BCBA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2018
Last Update Date: 05/02/2026
Certification Date: 05/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3550 CAMINO DEL RIO N STE 104
SAN DIEGO CA
92108-1738
US

IV. Provider business mailing address

PO BOX 231831
ENCINITAS CA
92023-1831
US

V. Phone/Fax

Practice location:
  • Phone: 760-634-1125
  • Fax:
Mailing address:
  • Phone: 760-634-1125
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-22-57797
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: