Provider Demographics
NPI:1932601952
Name:SIM, JIEUN
Entity Type:Individual
Prefix:
First Name:JIEUN
Middle Name:
Last Name:SIM
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 1:11832 ROSECRANS AVE # 127
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CA
Mailing Address - Zip Code:90650-4107
Mailing Address - Country:US
Mailing Address - Phone:909-680-8683
Mailing Address - Fax:
Practice Address - Street 1:6714 BEACH BLVD
Practice Address - Street 2:
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90621-3410
Practice Address - Country:US
Practice Address - Phone:714-752-6778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-06
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95008562363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily