Provider Demographics
NPI:1285908673
Name:KIM, JESSICA (PA-C, DC, LAC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:PA-C, DC, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 PLAZA DEL AMO UNIT 112
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90501-3406
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1125 E 16TH ST
Practice Address - Street 2:SUITE 4
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91784-9179
Practice Address - Country:US
Practice Address - Phone:909-297-3531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-02
Last Update Date:2017-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC 32286111NS0005X
CAAC 14601171100000X
CA55087363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No111NS0005XChiropractic ProvidersChiropractorSports Physician
No171100000XOther Service ProvidersAcupuncturist