Basic Information
| Provider Information | |||||||||
| NPI: | 1174053987 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | JANE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8702 248TH ST | ||||||||
| Address2: | |||||||||
| City: | BELLEROSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114262008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9175027121 | ||||||||
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| Practice Location | |||||||||
| Address1: | 15050 14TH RD | ||||||||
| Address2: | |||||||||
| City: | WHITESTONE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113572609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187670091 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2017 | ||||||||
| LastUpdateDate: | 10/19/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 027917 | NY | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 05293105 | 05 | NY | MEDICAID |