Provider Demographics
NPI:1225656432
Name:KIM, JESSICA STEPHANIE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:STEPHANIE
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 1:6443 N NORTHWEST HWY # B
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60631-1470
Mailing Address - Country:US
Mailing Address - Phone:248-219-3017
Mailing Address - Fax:
Practice Address - Street 1:5656 S MARYLAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637
Practice Address - Country:US
Practice Address - Phone:773-702-1220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-14
Last Update Date:2022-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041399309163WE0003X
CA95236442163WE0003X
CA95016336363LA2100X
IL209.021840363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163WE0003XNursing Service ProvidersRegistered NurseEmergency
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209.021840OtherDEPARTMENT OF FINANCIAL AND PROFESSIONAL REGULATION