Provider Demographics
NPI:1902353204
Name:KIM, JAEWON
Entity Type:Individual
Prefix:
First Name:JAEWON
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7400 ARTESIA BLVD APT 1107
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90621
Mailing Address - Country:US
Mailing Address - Phone:808-636-0094
Mailing Address - Fax:
Practice Address - Street 1:7400 ARTESIA BLVD APT 1107
Practice Address - Street 2:
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90621-3963
Practice Address - Country:US
Practice Address - Phone:808-636-0094
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-02
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOTA3462224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant