Healthcare Provider Details

I. General information

NPI: 1003796814
Provider Name (Legal Business Name): JEONGMIN JIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2025
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

521 FIFTH AVE UNIT A
CHARDON OH
44024-1088
US

IV. Provider business mailing address

22001 FAIRMOUNT BLVD
SHAKER HEIGHTS OH
44118-4819
US

V. Phone/Fax

Practice location:
  • Phone: 440-286-1553
  • Fax:
Mailing address:
  • Phone: 216-932-2800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.2613405
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: