Provider Demographics
NPI:1962236133
Name:KIM, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7045 CHARMANT DR APT 161
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92122-4373
Mailing Address - Country:US
Mailing Address - Phone:858-877-8300
Mailing Address - Fax:
Practice Address - Street 1:3350 LA VILLAGE DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92161-0001
Practice Address - Country:US
Practice Address - Phone:858-552-8585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-29
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID3361075183500000X
CA90050183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist