Provider Demographics
NPI:1235469776
Name:IM, JAE-WOO (OT)
Entity Type:Individual
Prefix:
First Name:JAE-WOO
Middle Name:
Last Name:IM
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8925 TAWES ST
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:MD
Mailing Address - Zip Code:20759-2582
Mailing Address - Country:US
Mailing Address - Phone:240-997-0326
Mailing Address - Fax:410-928-4907
Practice Address - Street 1:8925 TAWES ST
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:MD
Practice Address - Zip Code:20759-2582
Practice Address - Country:US
Practice Address - Phone:240-997-0326
Practice Address - Fax:410-928-4907
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-06
Last Update Date:2014-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD05416225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist