Provider Demographics
NPI:1902512650
Name:KIM, JACKIE SIHYUN
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:SIHYUN
Last Name:KIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1493 CAMBRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-1047
Mailing Address - Country:US
Mailing Address - Phone:617-758-8039
Mailing Address - Fax:
Practice Address - Street 1:1493 CAMBRIDGE ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139-1047
Practice Address - Country:US
Practice Address - Phone:407-729-3863
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-26
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA78676235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist