Healthcare Provider Details

I. General information

NPI: 1124801972
Provider Name (Legal Business Name): JAI EUN HUH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2023
Last Update Date: 08/22/2024
Certification Date: 08/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1240 FARMERS LN
SANTA ROSA CA
95405-6707
US

IV. Provider business mailing address

1240 FARMERS LN
SANTA ROSA CA
95405-6707
US

V. Phone/Fax

Practice location:
  • Phone: 707-536-0225
  • Fax:
Mailing address:
  • Phone: 707-536-0225
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number110501
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: