Provider Demographics
NPI:1518347988
Name:KIM, JENNIE (MD)
Entity Type:Individual
Prefix:
First Name:JENNIE
Middle Name:
Last Name:KIM
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 1:2051 MARENGO ST RM C5L100
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033-1352
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2051 MARENGO ST RM C5L100
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-1352
Practice Address - Country:US
Practice Address - Phone:323-409-8604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-01
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1730962086S0102X, 2086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care