Basic Information
| Provider Information | |||||||||
| NPI: | 1053790048 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHUN | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PHD, QMHP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3180 CENTER ST NE # 3360 | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973014532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035885351 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3180 CENTER ST NE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973014532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035885351 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2015 | ||||||||
| LastUpdateDate: | 11/01/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1053790048 | 05 | OR | MEDICAID |