Healthcare Provider Details

I. General information

NPI: 1104561455
Provider Name (Legal Business Name): JIYOUNG SUH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2022
Last Update Date: 06/08/2023
Certification Date: 06/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 MOORPARK AVE STE 300
SAN JOSE CA
95128-2680
US

IV. Provider business mailing address

2400 MOORPARK AVE STE 300
SAN JOSE CA
95128-2680
US

V. Phone/Fax

Practice location:
  • Phone: 408-975-2730
  • Fax:
Mailing address:
  • Phone: 408-975-2730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberASW115188
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: