Provider Demographics
NPI:1205214194
Name:KIM, JEAN (PHD)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1660 S. COLUMBIAN WAY
Mailing Address - Street 2:S-116-MHC
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98108-1597
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1660 S. COLUMBIAN WAY
Practice Address - Street 2:S-116-MHC
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98108-1597
Practice Address - Country:US
Practice Address - Phone:989-430-9847
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-11
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X, 390200000X
WAPY60847665103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program