Provider Demographics
NPI:1164691226
Name:KIM, JEANNIE S
Entity Type:Individual
Prefix:
First Name:JEANNIE
Middle Name:S
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 1:13510 MEGANWOOD PL
Mailing Address - Street 2:
Mailing Address - City:LA MIRADA
Mailing Address - State:CA
Mailing Address - Zip Code:90638-6524
Mailing Address - Country:US
Mailing Address - Phone:562-943-1616
Mailing Address - Fax:
Practice Address - Street 1:13510 MEGANWOOD PL
Practice Address - Street 2:
Practice Address - City:LA MIRADA
Practice Address - State:CA
Practice Address - Zip Code:90638-6524
Practice Address - Country:US
Practice Address - Phone:562-943-1616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-22
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker