Provider Demographics
NPI:1598593188
Name:KANG, JUNG HWA (PSYD)
Entity type:Individual
Prefix:
First Name:JUNG HWA
Middle Name:
Last Name:KANG
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6820 PARKDALE PL STE 115
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254-4699
Mailing Address - Country:US
Mailing Address - Phone:317-329-7300
Mailing Address - Fax:317-329-7325
Practice Address - Street 1:6820 PARKDALE PL STE 115
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-4699
Practice Address - Country:US
Practice Address - Phone:317-329-7300
Practice Address - Fax:317-329-7325
Is Sole Proprietor?:No
Enumeration Date:2024-07-24
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20043841A103TC0700X, 103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300097867Medicaid
IN1104430576OtherANTHEM PTAN