Provider Demographics
NPI:1417313313
Name:TITTLE-KIM, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:TITTLE-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 1:285 SOUTH ST
Mailing Address - Street 2:SUITE J
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-5037
Mailing Address - Country:US
Mailing Address - Phone:805-547-7025
Mailing Address - Fax:805-547-7029
Practice Address - Street 1:285 SOUTH ST
Practice Address - Street 2:SUITE J
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-5037
Practice Address - Country:US
Practice Address - Phone:805-547-7025
Practice Address - Fax:805-547-7029
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-07
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor