Healthcare Provider Details

I. General information

NPI: 1013535921
Provider Name (Legal Business Name): JESSICA PHUNG DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2020
Last Update Date: 01/28/2021
Certification Date: 01/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2552 WALNUT AVE STE 130
TUSTIN CA
92780-6970
US

IV. Provider business mailing address

22 ODYSSEY STE 165
IRVINE CA
92618-3194
US

V. Phone/Fax

Practice location:
  • Phone: 714-508-1600
  • Fax:
Mailing address:
  • Phone: 949-727-2192
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number298432
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: