Healthcare Provider Details

I. General information

NPI: 1609795293
Provider Name (Legal Business Name): JI WON KIM
Entity Type: Individual
Gender:
Sole Proprietor: N

Provider Other Name: JIWON KIM

II. Dates (important events)

Enumeration Date: 07/15/2026
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9000 W WISCONSIN AVE
MILWAUKEE WI
53226-4874
US

IV. Provider business mailing address

2934 BRYANT AVE S UNIT 520
MINNEAPOLIS MN
55408-5076
US

V. Phone/Fax

Practice location:
  • Phone: 414-266-3339
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: