Healthcare Provider Details

I. General information

NPI: 1619009255
Provider Name (Legal Business Name): JEEAE SOPHIE HWANG R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JEE AE HWANG R.D.

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 12/20/2021
Certification Date: 12/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 MERCED ST
SAN LEANDRO CA
94577-4201
US

IV. Provider business mailing address

2500 MERCED STREET NUTRITION SERVICES DEPARTMENT
SAN LEANDRO CA
94577
US

V. Phone/Fax

Practice location:
  • Phone: 510-454-3438
  • Fax:
Mailing address:
  • Phone: 510-454-3438
  • Fax: 510-752-6550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: