Provider Demographics
NPI:1063932051
Name:KIM, JOLENE (DO)
Entity type:Individual
Prefix:
First Name:JOLENE
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7405 RENNER RD
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:KS
Mailing Address - Zip Code:66217-9414
Mailing Address - Country:US
Mailing Address - Phone:913-588-8465
Mailing Address - Fax:913-588-8529
Practice Address - Street 1:7405 RENNER RD
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:KS
Practice Address - Zip Code:66217-9414
Practice Address - Country:US
Practice Address - Phone:913-588-8465
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-21
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017020109207Q00000X
KS05-43555207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine