Provider Demographics
NPI:1447589692
Name:KIM, JEANNE (PSYD)
Entity Type:Individual
Prefix:
First Name:JEANNE
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21053 DEVONSHIRE ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CHATSWORTH
Mailing Address - State:CA
Mailing Address - Zip Code:91311-2364
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21053 DEVONSHIRE ST
Practice Address - Street 2:SUITE 101
Practice Address - City:CHATSWORTH
Practice Address - State:CA
Practice Address - Zip Code:91311-2364
Practice Address - Country:US
Practice Address - Phone:818-726-5326
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-17
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY22888103TA0700X, 103TC0700X, 103G00000X
CAPSY 22888103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY228880Medicaid
CACV764ZMedicare PIN