Provider Demographics
NPI:1407059843
Name:LIM, JENNIFER C (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:C
Last Name:LIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 S COLLEGEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:COLLEGEVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19426-2998
Mailing Address - Country:US
Mailing Address - Phone:702-733-7866
Mailing Address - Fax:
Practice Address - Street 1:4230 BURNHAM AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119
Practice Address - Country:US
Practice Address - Phone:702-733-7866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ34161207ZC0500X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100512696Medicaid
AZ34161OtherMEDICAL LICENSE
NV12350OtherMEDICAL LICENSE
AZI32660Medicare UPIN
NV100512696Medicaid