Provider Demographics
NPI:1598082760
Name:KIM, JENNA SEO JIYEUN (NP)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:SEO JIYEUN
Last Name:KIM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JI
Other - Middle Name:YEUN
Other - Last Name:SEO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:8201 NEWMAN AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92647-7043
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8201 NEWMAN AVE STE 101
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-7043
Practice Address - Country:US
Practice Address - Phone:714-847-6900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-28
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20832363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant