Provider Demographics
NPI:1144725490
Name:JO, SEUNGBIN (ATC)
Entity type:Individual
Prefix:
First Name:SEUNGBIN
Middle Name:
Last Name:JO
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:DANIEL
Other - Middle Name:
Other - Last Name:JO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:ATC
Mailing Address - Street 1:2930 DRIFTWOOD PL APT 61
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-8027
Mailing Address - Country:US
Mailing Address - Phone:601-497-8489
Mailing Address - Fax:
Practice Address - Street 1:3601 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95211-6322
Practice Address - Country:US
Practice Address - Phone:601-497-8489
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-28
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program