Provider Demographics
NPI:1992517932
Name:KIM, JAEWON (BS)
Entity type:Individual
Prefix:
First Name:JAEWON
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1321 E 4600 S APT 1140
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-3328
Mailing Address - Country:US
Mailing Address - Phone:801-644-6718
Mailing Address - Fax:
Practice Address - Street 1:1321 E 4600 S APT 1140
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-3328
Practice Address - Country:US
Practice Address - Phone:801-644-6718
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-27
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer