Provider Demographics
NPI:1992438477
Name:KIM, JACEY
Entity type:Individual
Prefix:
First Name:JACEY
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 1:859 N HELIOTROPE DR
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90029-2521
Mailing Address - Country:US
Mailing Address - Phone:213-435-5125
Mailing Address - Fax:
Practice Address - Street 1:3030 W OLYMPIC BLVD STE 209
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-6501
Practice Address - Country:US
Practice Address - Phone:213-800-3088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-02
Last Update Date:2022-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95020833363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily