Provider Demographics
NPI:1982156626
Name:KIM, JESSICA MIFA (LMFT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:MIFA
Last Name:KIM
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMFT
Mailing Address - Street 1:4707 GAMBIER ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90032-2017
Mailing Address - Country:US
Mailing Address - Phone:310-800-0881
Mailing Address - Fax:
Practice Address - Street 1:4707 GAMBIER ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90032-2017
Practice Address - Country:US
Practice Address - Phone:310-800-0881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-28
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA118456106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95-2633765OtherMEDI-CAL