Provider Demographics
NPI:1154462216
Name:KANG, JEANNIE SOOK (LAC)
Entity type:Individual
Prefix:
First Name:JEANNIE
Middle Name:SOOK
Last Name:KANG
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:547 N PLYMOUTH BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90004-1410
Mailing Address - Country:US
Mailing Address - Phone:323-871-4821
Mailing Address - Fax:
Practice Address - Street 1:822 S ROBERTSON BLVD
Practice Address - Street 2:#105
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90035-1613
Practice Address - Country:US
Practice Address - Phone:310-854-7788
Practice Address - Fax:310-854-3308
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6684171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist