Provider Demographics
NPI:1447792767
Name:KIM, JIEUN (HIS)
Entity Type:Individual
Prefix:MRS
First Name:JIEUN
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16014 24TH ST E
Mailing Address - Street 2:
Mailing Address - City:LAKE TAPPS
Mailing Address - State:WA
Mailing Address - Zip Code:98391-4908
Mailing Address - Country:US
Mailing Address - Phone:253-886-0855
Mailing Address - Fax:253-941-3896
Practice Address - Street 1:18802 MOUNTAIN VIEW DR E
Practice Address - Street 2:
Practice Address - City:BONNEY LAKE
Practice Address - State:WA
Practice Address - Zip Code:98391-7110
Practice Address - Country:US
Practice Address - Phone:253-886-0855
Practice Address - Fax:253-941-3896
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-17
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAHA60239129237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist