Healthcare Provider Details

I. General information

NPI: 1952205213
Provider Name (Legal Business Name): JE-WOO IM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2026
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 E HURON ST STE 1-200
CHICAGO IL
60611-2909
US

IV. Provider business mailing address

1422 N LA SALLE DR APT 307
CHICAGO IL
60610-6416
US

V. Phone/Fax

Practice location:
  • Phone: 312-503-7975
  • Fax:
Mailing address:
  • Phone: 408-510-9768
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: