Healthcare Provider Details

I. General information

NPI: 1689022907
Provider Name (Legal Business Name): JEEYOON JUNG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2016
Last Update Date: 07/12/2022
Certification Date: 07/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 E VANDERBILT WAY
SAN BERNARDINO CA
92415-2004
US

IV. Provider business mailing address

303 E VANDERBILT WAY
SAN BERNARDINO CA
92415-0026
US

V. Phone/Fax

Practice location:
  • Phone: 909-458-1350
  • Fax:
Mailing address:
  • Phone: 909-458-1350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberA151445
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: