Provider Demographics
NPI:1760726525
Name:KIM, JAE HOON (CRNP-PMH)
Entity Type:Individual
Prefix:MR
First Name:JAE HOON
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:CRNP-PMH
Other - Prefix:
Other - First Name:JAEHOON
Other - Middle Name:
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNP-PMH
Mailing Address - Street 1:7201 WISCONSIN AVE STE 440
Mailing Address - Street 2:
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20814-4851
Mailing Address - Country:US
Mailing Address - Phone:202-236-4669
Mailing Address - Fax:
Practice Address - Street 1:7201 WISCONSIN AVE STE 440
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20814-4851
Practice Address - Country:US
Practice Address - Phone:202-236-4669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-19
Last Update Date:2022-08-19
Deactivation Date:2020-07-10
Deactivation Code:
Reactivation Date:2020-07-22
Provider Licenses
StateLicense IDTaxonomies
VA0024178821363LP0808X
MDR189134363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD587108500Medicaid
MD822275Medicaid
MD822275Medicaid