Healthcare Provider Details

I. General information

NPI: 1245014703
Provider Name (Legal Business Name): HYUN JUNG AHN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2023
Last Update Date: 08/24/2023
Certification Date: 08/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10180 SE SUNNYSIDE RD
CLACKAMAS OR
97015-8970
US

IV. Provider business mailing address

311 NW 12TH AVE UNIT 501
PORTLAND OR
97209-2992
US

V. Phone/Fax

Practice location:
  • Phone: 503-813-2000
  • Fax:
Mailing address:
  • Phone: 559-824-7020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number65036
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: