Provider Demographics
NPI:1285408120
Name:PHUNG, JENNY (OTR/L)
Entity type:Individual
Prefix:
First Name:JENNY
Middle Name:
Last Name:PHUNG
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8681 KATELLA AVE SPC 153
Mailing Address - Street 2:
Mailing Address - City:STANTON
Mailing Address - State:CA
Mailing Address - Zip Code:90680-4278
Mailing Address - Country:US
Mailing Address - Phone:626-739-0680
Mailing Address - Fax:
Practice Address - Street 1:12131 BROOKHURST ST
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92840-2863
Practice Address - Country:US
Practice Address - Phone:714-684-8188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-10
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25169225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist