Provider Demographics
NPI:1992720163
Name:SUN, JEAN K (PT)
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:K
Last Name:SUN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23456 HAWTHORNE BLVD
Mailing Address - Street 2:SUITE 300B
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-4716
Mailing Address - Country:US
Mailing Address - Phone:310-316-6190
Mailing Address - Fax:310-316-1788
Practice Address - Street 1:23456 HAWTHORNE BLVD.
Practice Address - Street 2:SUITE 300B
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-4716
Practice Address - Country:US
Practice Address - Phone:310-316-6190
Practice Address - Fax:310-316-1788
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2008-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT13312225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT13312AMedicare ID - Type Unspecified
CAWPT13312AMedicare UPIN