Provider Demographics
NPI:1861378044
Name:KIM, JAEEUN
Entity type:Individual
Prefix:
First Name:JAEEUN
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 ESMOND PL
Mailing Address - Street 2:
Mailing Address - City:TENAFLY
Mailing Address - State:NJ
Mailing Address - Zip Code:07670-1608
Mailing Address - Country:US
Mailing Address - Phone:201-421-6566
Mailing Address - Fax:
Practice Address - Street 1:1011 N UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109-1078
Practice Address - Country:US
Practice Address - Phone:201-421-6566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-13
Last Update Date:2025-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program