Provider Demographics
NPI:1083113096
Name:SHIM, JAEBIN (MSED, ATC, CSCS)
Entity Type:Individual
Prefix:
First Name:JAEBIN
Middle Name:
Last Name:SHIM
Suffix:
Gender:M
Credentials:MSED, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 HACKBERRY
Mailing Address - Street 2:PO BOX 622
Mailing Address - City:GOODWELL
Mailing Address - State:OK
Mailing Address - Zip Code:73939
Mailing Address - Country:US
Mailing Address - Phone:703-303-0015
Mailing Address - Fax:
Practice Address - Street 1:323 EAGLE BLVD.
Practice Address - Street 2:
Practice Address - City:GOODWELL
Practice Address - State:OK
Practice Address - Zip Code:73939
Practice Address - Country:US
Practice Address - Phone:580-349-1338
Practice Address - Fax:580-349-1419
Is Sole Proprietor?:No
Enumeration Date:2018-02-05
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK8472255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer