Provider Demographics
NPI:1083155824
Name:JMK COMMUNITY HEALTH CENTER, INC
Entity Type:Organization
Organization Name:JMK COMMUNITY HEALTH CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:JEANETTE
Authorized Official - Middle Name:MONIQUE
Authorized Official - Last Name:KIDD
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:424-396-3412
Mailing Address - Street 1:1112 N SANTA FE AVE
Mailing Address - Street 2:
Mailing Address - City:COMPTON
Mailing Address - State:CA
Mailing Address - Zip Code:90221-1427
Mailing Address - Country:US
Mailing Address - Phone:310-638-1100
Mailing Address - Fax:424-396-3427
Practice Address - Street 1:14111 VAN NESS AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90249-2950
Practice Address - Country:US
Practice Address - Phone:424-396-3412
Practice Address - Fax:424-396-3427
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-13
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1144584806Medicaid