Provider Demographics
NPI:1154636603
Name:KIM, JAKE T (LICSW)
Entity Type:Individual
Prefix:MR
First Name:JAKE
Middle Name:T
Last Name:KIM
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 25608
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0608
Mailing Address - Country:US
Mailing Address - Phone:206-320-4476
Mailing Address - Fax:206-568-7043
Practice Address - Street 1:7320 216TH ST SW
Practice Address - Street 2:SUITE 200
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026-8006
Practice Address - Country:US
Practice Address - Phone:425-640-4900
Practice Address - Fax:425-640-4919
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-09
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0817331041C0700X
WALW602183641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical