Provider Demographics
NPI:1205573870
Name:KIM, JACLYN JEONGHOON (MD)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:JEONGHOON
Last Name:KIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:JEONGHOON
Other - Last Name:MARSH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 776084
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6084
Mailing Address - Country:US
Mailing Address - Phone:314-731-1113
Mailing Address - Fax:314-731-4020
Practice Address - Street 1:755 DUNN RD STE 110
Practice Address - Street 2:
Practice Address - City:HAZELWOOD
Practice Address - State:MO
Practice Address - Zip Code:63042-1753
Practice Address - Country:US
Practice Address - Phone:314-731-1113
Practice Address - Fax:314-731-4020
Is Sole Proprietor?:No
Enumeration Date:2022-05-16
Last Update Date:2025-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2025029327207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine