Provider Demographics
NPI:1679242960
Name:MO, JENNY JEYOUNG
Entity type:Individual
Prefix:
First Name:JENNY
Middle Name:JEYOUNG
Last Name:MO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JEYOUNG
Other - Middle Name:
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AGACNP-BC
Mailing Address - Street 1:PO BOX 35380
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89133-5380
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1661 GOLDEN RAIN RD
Practice Address - Street 2:
Practice Address - City:SEAL BEACH
Practice Address - State:CA
Practice Address - Zip Code:90740-4907
Practice Address - Country:US
Practice Address - Phone:562-493-9581
Practice Address - Fax:562-795-6389
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-09
Last Update Date:2025-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95015642363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care