Healthcare Provider Details

I. General information

NPI: 1629616966
Provider Name (Legal Business Name): JIMMY HWANG OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2019
Last Update Date: 12/17/2019
Certification Date: 12/17/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

802 E US HIGHWAY 20
MICHIGAN CITY IN
46360-7424
US

IV. Provider business mailing address

5855 N CALIFORNIA AVE
CHICAGO IL
60659-3902
US

V. Phone/Fax

Practice location:
  • Phone: 219-872-7251
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056.012846
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number31006830A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: