Provider Demographics
NPI:1306842554
Name:KIM, JENNIFER (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:GI-IN
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:11790 SW BARNES RD STE 330
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-5935
Mailing Address - Country:US
Mailing Address - Phone:503-228-4414
Mailing Address - Fax:503-228-7293
Practice Address - Street 1:11790 SW BARNES RD STE 330
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5935
Practice Address - Country:US
Practice Address - Phone:503-228-4414
Practice Address - Fax:503-228-7293
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR126243207RS0012X
CT042436207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I09581Medicare UPIN
CT110009257Medicare ID - Type Unspecified