Provider Demographics
NPI:1164018503
Name:KIM-HOSSEIN, JEAN HEE
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:HEE
Last Name:KIM-HOSSEIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JEAN
Other - Middle Name:HEE
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14885 TELEGRAPH RD
Mailing Address - Street 2:
Mailing Address - City:LA MIRADA
Mailing Address - State:CA
Mailing Address - Zip Code:90638-1060
Mailing Address - Country:US
Mailing Address - Phone:562-777-3405
Mailing Address - Fax:
Practice Address - Street 1:14885 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:LA MIRADA
Practice Address - State:CA
Practice Address - Zip Code:90638-1060
Practice Address - Country:US
Practice Address - Phone:562-777-3405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-20
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA83482183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1164018503Medicaid