Provider Demographics
NPI:1003458977
Name:KIM, JESSICA JAEHEE (PA-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:JAEHEE
Last Name:KIM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2731 BRIERHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:LA CRESCENTA
Mailing Address - State:CA
Mailing Address - Zip Code:91214-1403
Mailing Address - Country:US
Mailing Address - Phone:818-484-0802
Mailing Address - Fax:
Practice Address - Street 1:4950 SAN BERNARDINO ST STE 200
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:CA
Practice Address - Zip Code:91763-2328
Practice Address - Country:US
Practice Address - Phone:909-621-7647
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-11
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA57333363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical