Provider Demographics
NPI:1063889632
Name:KANG, MIN JUNG SOPHIA (PMHNP)
Entity type:Individual
Prefix:MRS
First Name:MIN JUNG
Middle Name:SOPHIA
Last Name:KANG
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500N STATE ST
Mailing Address - Street 2:JMM ROOM 2525
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-5815
Mailing Address - Fax:601-984-5842
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-5815
Practice Address - Fax:601-984-5842
Is Sole Proprietor?:No
Enumeration Date:2015-08-30
Last Update Date:2016-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR852417363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05024859Medicaid
MSP01676210Medicare PIN
MS05024859Medicaid