Provider Demographics
NPI:1144180035
Name:CHUNG, JACOB THOMAS (PT, DPT)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:THOMAS
Last Name:CHUNG
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3230 E IMPERIAL HWY STE 100
Mailing Address - Street 2:
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92821-6735
Mailing Address - Country:US
Mailing Address - Phone:714-256-5074
Mailing Address - Fax:714-256-0070
Practice Address - Street 1:24301 MUIRLANDS BLVD
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-3627
Practice Address - Country:US
Practice Address - Phone:949-271-0012
Practice Address - Fax:949-271-0013
Is Sole Proprietor?:No
Enumeration Date:2025-11-13
Last Update Date:2025-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA309116225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist