Provider Demographics
NPI:1083379416
Name:KIM, JINYOUNG (PT, LAC)
Entity type:Individual
Prefix:
First Name:JINYOUNG
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:PT, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22304 56TH RD FL 2
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11364-2040
Mailing Address - Country:US
Mailing Address - Phone:201-732-3333
Mailing Address - Fax:
Practice Address - Street 1:22304 56TH RD FL 2
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11364-2040
Practice Address - Country:US
Practice Address - Phone:201-732-3333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-01
Last Update Date:2025-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007726171100000X
NY042377225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No171100000XOther Service ProvidersAcupuncturist