Provider Demographics
NPI:1104101591
Name:KIM, JIYON
Entity type:Individual
Prefix:MS
First Name:JIYON
Middle Name:
Last Name:KIM
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 1:1991 MARCUS AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11042-2057
Mailing Address - Country:US
Mailing Address - Phone:516-358-1808
Mailing Address - Fax:646-754-9854
Practice Address - Street 1:1991 MARCUS AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-2057
Practice Address - Country:US
Practice Address - Phone:516-358-1808
Practice Address - Fax:646-754-9854
Is Sole Proprietor?:No
Enumeration Date:2011-10-17
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY021316103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program