MEDICARE: YE KYUNG JEONG NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	95016261	CA

General Provider Information

NPI Number	:	1376237446
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	YE KYUNG JEONG NP

Provider Business Mailing Address
First Line	:	1751 VALLECITO DR
Second Line	:
City	:	HACIENDA HEIGHTS
State	:	CA
Zip	:	91745-3343
Country	:	US
Telephone Number	:	626-224-6064
Fax Number	:

Provider Business Practice Location Address
First Line	:	19745 COLIMA RD STE 12
Second Line	:
City	:	ROWLAND HEIGHTS
State	:	CA
Zip	:	91748-3219
Country	:	US
Telephone Number	:	909-595-5550
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/02/2023
Last Update Date	:	06/02/2023

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