Provider Demographics
NPI:1871776583
Name:JEON, WOONG SOO (LAC)
Entity type:Individual
Prefix:MR
First Name:WOONG SOO
Middle Name:
Last Name:JEON
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9175 MISSION GORGE RD.
Mailing Address - Street 2:
Mailing Address - City:SANTEE
Mailing Address - State:CA
Mailing Address - Zip Code:92071
Mailing Address - Country:US
Mailing Address - Phone:619-213-2175
Mailing Address - Fax:619-449-7788
Practice Address - Street 1:9175 MISSION GORGE RD.
Practice Address - Street 2:
Practice Address - City:SANTEE
Practice Address - State:CA
Practice Address - Zip Code:92071
Practice Address - Country:US
Practice Address - Phone:619-213-2175
Practice Address - Fax:619-449-7788
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-17
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC11565171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist