Provider Demographics
NPI:1215258785
Name:KOO, JA JAUNG
Entity type:Individual
Prefix:
First Name:JA
Middle Name:JAUNG
Last Name:KOO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:835 S LUCERNE BLVD APT 205
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90005-3793
Mailing Address - Country:US
Mailing Address - Phone:323-892-7711
Mailing Address - Fax:
Practice Address - Street 1:959 CRENSHAW BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90019-1938
Practice Address - Country:US
Practice Address - Phone:323-939-7911
Practice Address - Fax:323-939-9304
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-18
Last Update Date:2010-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60875183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist