Healthcare Provider Details

I. General information

NPI: 1639525751
Provider Name (Legal Business Name): ANDREW JEON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2016
Last Update Date: 10/21/2022
Certification Date: 10/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9600 VETERANS DR SW # 1A116MHC
TACOMA WA
98493-3786
US

IV. Provider business mailing address

9600 VETERANS DR SW # 1A116MHC
TACOMA WA
98493-0003
US

V. Phone/Fax

Practice location:
  • Phone: 253-583-2729
  • Fax:
Mailing address:
  • Phone: 253-583-2729
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number105211
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: