Provider Demographics
NPI:1962582817
Name:CHUNG, JEANIE HEE-KYUNG (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:JEANIE
Middle Name:HEE-KYUNG
Last Name:CHUNG
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:HEE KYUNG
Other - Middle Name:
Other - Last Name:LEDDON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:7300 RANCH ROAD 2222, BUILDING 1, STE 200
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78730
Mailing Address - Country:US
Mailing Address - Phone:512-628-0465
Mailing Address - Fax:
Practice Address - Street 1:925 RUSH DR
Practice Address - Street 2:
Practice Address - City:SALIDA
Practice Address - State:CO
Practice Address - Zip Code:81201-9665
Practice Address - Country:US
Practice Address - Phone:719-539-4600
Practice Address - Fax:719-539-4629
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO38765174400000X
COCDRH.0038765207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO014977OtherKAISER COMMERCIAL NUMBER
CO82157227Medicaid