Healthcare Provider Details

I. General information

NPI: 1942889977
Provider Name (Legal Business Name): LILY YOUJEONG JEONG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LILY JEONG

II. Dates (important events)

Enumeration Date: 04/06/2021
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 PARNASSUS AVE
SAN FRANCISCO CA
94143-2203
US

IV. Provider business mailing address

1959 NE PACIFIC ST
SEATTLE WA
98195-0001
US

V. Phone/Fax

Practice location:
  • Phone: 415-353-2507
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberA207343
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: