Healthcare Provider Details

I. General information

NPI: 1154800902
Provider Name (Legal Business Name): JIWON KANG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2018
Last Update Date: 10/09/2026
Certification Date: 08/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4010 77TH STREET, 1D 1D
ELMHURST NY
11373
US

IV. Provider business mailing address

4010 77TH ST
ELMHURST NY
11373-1155
US

V. Phone/Fax

Practice location:
  • Phone: 646-239-6072
  • Fax:
Mailing address:
  • Phone: 646-239-6072
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number104331
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: