Provider Demographics
NPI:1346859592
Name:KIM, JISUN (OTR/L)
Entity Type:Individual
Prefix:MISS
First Name:JISUN
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:MISS
Other - First Name:IRENE
Other - Middle Name:
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OTR/L
Mailing Address - Street 1:6172 INDIANA AVE
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90621-2566
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:875 N BREA BLVD
Practice Address - Street 2:
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821-2606
Practice Address - Country:US
Practice Address - Phone:714-529-6842
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-23
Last Update Date:2022-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22683225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist