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General NPI Number Information
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NPI Number | 1487460671
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Entity Type | Individual
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Provider Name | GRACE Y JUNG
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Gender | Female
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Dates
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Enumeration Date | 12/04/2024
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Last Update Date | 12/04/2024
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Provider Practice Location Address
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Address Line | 4444 HERITAGE TRACE PKWY STE 408
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City | FORT WORTH
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State | TX
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Zip | 76244-8944
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Country | US
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Telephone | 817-283-5252
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Fax |
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Provider Business Mailing Address
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Address Line | 5032 STEINBECK ST
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City | CARROLLTON
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State | TX
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Zip | 75010-5001
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Country | US
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Telephone | 469-536-1460
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA18387
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License Number State | TX
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