Provider Demographics
NPI:1306375258
Name:KIM, JESSIE
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 HALLOCK RD STE 209
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-3082
Mailing Address - Country:US
Mailing Address - Phone:631-338-8516
Mailing Address - Fax:518-984-3120
Practice Address - Street 1:115 W 45TH ST STE 503
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10036-4005
Practice Address - Country:US
Practice Address - Phone:646-983-0085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-05
Last Update Date:2024-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY034901225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist