Provider Demographics
NPI:1356837496
Name:KIM, JAY (NP)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:SUNGMIN
Other - Middle Name:
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:9201 W SUNSET BLVD
Mailing Address - Street 2:STE 820
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90069-3701
Mailing Address - Country:US
Mailing Address - Phone:310-550-1010
Mailing Address - Fax:310-550-0650
Practice Address - Street 1:87 N WILSON AVE APT 1
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91106-2318
Practice Address - Country:US
Practice Address - Phone:703-981-2924
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-02
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95069185363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health