Provider Demographics
NPI:1114159597
Name:KIM, JO SUZANNE (PT)
Entity Type:Individual
Prefix:
First Name:JO
Middle Name:SUZANNE
Last Name:KIM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JO
Other - Middle Name:S
Other - Last Name:ROGERS-KIM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:18666 PARK MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-6816
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18666 PARK MEADOW LANE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92648-6663
Practice Address - Country:US
Practice Address - Phone:949-932-2960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-18
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 21327225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist