Provider Demographics
NPI:1992067508
Name:KIM, JENNIFER (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8080 PARKWAY DR
Mailing Address - Street 2:2ND FL
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-2104
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8080 PARKWAY DR
Practice Address - Street 2:2ND FL
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-2104
Practice Address - Country:US
Practice Address - Phone:619-589-4939
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-10
Last Update Date:2021-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA127415207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine