Provider Demographics
NPI:1114133642
Name:KIM, JODY SOOK (LAC,OMD)
Entity Type:Individual
Prefix:DR
First Name:JODY
Middle Name:SOOK
Last Name:KIM
Suffix:
Gender:F
Credentials:LAC,OMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:706A N REILLY RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28303-5619
Mailing Address - Country:US
Mailing Address - Phone:910-868-8865
Mailing Address - Fax:
Practice Address - Street 1:706A N REILLY RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-5619
Practice Address - Country:US
Practice Address - Phone:910-868-8865
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7596171100000X
NC1053171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist