Provider Demographics
NPI:1720462674
Name:KIM, JAESUNG (LAC)
Entity type:Individual
Prefix:MR
First Name:JAESUNG
Middle Name:
Last Name:KIM
Suffix:
Gender:
Credentials:LAC
Other - Prefix:MR
Other - First Name:JAESUNG
Other - Middle Name:
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LAC
Mailing Address - Street 1:3618 193RD ST FL 2
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11358-2444
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:107 N 12TH ST STE 704
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11249-1022
Practice Address - Country:US
Practice Address - Phone:973-330-6444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-09
Last Update Date:2025-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005143171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist