Provider Demographics
NPI:1972655918
Name:KWON, JEONG AE (L,AC (OMD))
Entity type:Individual
Prefix:MRS
First Name:JEONG AE
Middle Name:
Last Name:KWON
Suffix:
Gender:F
Credentials:L,AC (OMD)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3069 LAWRENCE EXPY
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARA
Mailing Address - State:CA
Mailing Address - Zip Code:95051-0713
Mailing Address - Country:US
Mailing Address - Phone:408-830-0200
Mailing Address - Fax:408-830-0214
Practice Address - Street 1:3069 LAWRENCE EXPY
Practice Address - Street 2:
Practice Address - City:SANTA CLARA
Practice Address - State:CA
Practice Address - Zip Code:95051-0713
Practice Address - Country:US
Practice Address - Phone:408-830-0200
Practice Address - Fax:408-830-0214
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC7957171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist