Provider Demographics
NPI:1972788693
Name:IM, JOANNE JUNGSUN (PHD, LAC)
Entity type:Individual
Prefix:
First Name:JOANNE
Middle Name:JUNGSUN
Last Name:IM
Suffix:
Gender:F
Credentials:PHD, LAC
Other - Prefix:
Other - First Name:JUNG
Other - Middle Name:SUN
Other - Last Name:RO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAC
Mailing Address - Street 1:8300 OLD COURTHOUSE RD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3822
Mailing Address - Country:US
Mailing Address - Phone:703-595-9082
Mailing Address - Fax:
Practice Address - Street 1:8300 OLD COURTHOUSE RD
Practice Address - Street 2:SUITE 220
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22182-3822
Practice Address - Country:US
Practice Address - Phone:703-595-9082
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-31
Last Update Date:2009-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 11413171100000X
VA0121000533171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist