=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396559001
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AVA JEUNG
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2025
-----------------------------------------------------
Last Update Date | 02/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6153 COLGATE AVE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90036-3127
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-433-4165
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16001 LEGACY RD UNIT 302
-----------------------------------------------------
City | TUSTIN
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92782-2776
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-462-7983
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------