Healthcare Provider Details

I. General information

NPI: 1174433379
Provider Name (Legal Business Name): SUYEON JUNG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2026
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 MERCANTILE PLAZA DR STE 307
FORT WORTH TX
76137-4230
US

IV. Provider business mailing address

2832 RED WOLF DR
FORT WORTH TX
76244-5505
US

V. Phone/Fax

Practice location:
  • Phone: 817-754-7976
  • Fax: 817-232-9403
Mailing address:
  • Phone: 214-971-6443
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number96305
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: