Provider Demographics
NPI:1386786028
Name:JEONG, SOONJOO (LAC, DIPLAC)
Entity type:Individual
Prefix:
First Name:SOONJOO
Middle Name:
Last Name:JEONG
Suffix:
Gender:M
Credentials:LAC, DIPLAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:527 E. WINDSOR ROAD
Mailing Address - Street 2:#207
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205-4120
Mailing Address - Country:US
Mailing Address - Phone:818-242-4878
Mailing Address - Fax:
Practice Address - Street 1:527 E. WINDSOR ROAD
Practice Address - Street 2:#207
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205-4120
Practice Address - Country:US
Practice Address - Phone:818-242-4878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC9270171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
019220OtherNCCAOM ID #
CAAC9270OtherCALIFORNIA LICENSE