Provider Demographics
NPI:1366896367
Name:JUNG, KENNY (MSOM, LAC)
Entity type:Individual
Prefix:
First Name:KENNY
Middle Name:
Last Name:JUNG
Suffix:
Gender:M
Credentials:MSOM, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4525 SW 109TH AVE
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-3022
Mailing Address - Country:US
Mailing Address - Phone:503-643-3835
Mailing Address - Fax:
Practice Address - Street 1:4525 SW 109TH AVE
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-3022
Practice Address - Country:US
Practice Address - Phone:503-643-3835
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-16
Last Update Date:2016-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC150816171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist