Provider Demographics
NPI:1861724304
Name:SONG, JAEWON (AC)
Entity type:Individual
Prefix:DR
First Name:JAEWON
Middle Name:
Last Name:SONG
Suffix:
Gender:M
Credentials:AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17139 VENTURA BLVD #100
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316
Mailing Address - Country:US
Mailing Address - Phone:818-905-7575
Mailing Address - Fax:818-905-7772
Practice Address - Street 1:17139 VENTURA BLVD #100
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316
Practice Address - Country:US
Practice Address - Phone:818-905-7575
Practice Address - Fax:818-905-7772
Is Sole Proprietor?:No
Enumeration Date:2010-02-09
Last Update Date:2010-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC13297171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist