Healthcare Provider Details

I. General information

NPI: 1831882737
Provider Name (Legal Business Name): SUJIN JEUNG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2023
Last Update Date: 05/29/2023
Certification Date: 05/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21750 RED RUM DR STE 117
ASHBURN VA
20147-5867
US

IV. Provider business mailing address

43077 HUNTERS GREEN SQ
BROADLANDS VA
20148-4054
US

V. Phone/Fax

Practice location:
  • Phone: 703-574-2989
  • Fax:
Mailing address:
  • Phone: 301-789-3272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: