Provider Demographics
NPI:1558700427
Name:KIM, JESSICA KIM (DO)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:KIM
Last Name:KIM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:MRS
Other - First Name:JESSICA
Other - Middle Name:KIM
Other - Last Name:LASCOLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 30750
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27833-0750
Mailing Address - Country:US
Mailing Address - Phone:252-931-7638
Mailing Address - Fax:252-931-7694
Practice Address - Street 1:2101 W ARLINGTON BLVD STE 210
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-5758
Practice Address - Country:US
Practice Address - Phone:252-931-7638
Practice Address - Fax:252-931-7694
Is Sole Proprietor?:No
Enumeration Date:2013-06-24
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010207462085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology