Provider Demographics
NPI:1942608302
Name:KIM, JAEHYUN (OT)
Entity Type:Individual
Prefix:
First Name:JAEHYUN
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 S VIRGIL AVE
Mailing Address - Street 2:201
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90020-1416
Mailing Address - Country:US
Mailing Address - Phone:213-480-0021
Mailing Address - Fax:213-480-0621
Practice Address - Street 1:520 S VIRGIL AVE
Practice Address - Street 2:201
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90020-1416
Practice Address - Country:US
Practice Address - Phone:213-480-0021
Practice Address - Fax:213-480-0621
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-16
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT9178225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist