Provider Demographics
NPI:1609111665
Name:NGUYEN, JACQUELINE KIM (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:KIM
Last Name:NGUYEN
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 1:3273 CLAREMONT WAY
Mailing Address - Street 2:STE 100
Mailing Address - City:NAPA
Mailing Address - State:CA
Mailing Address - Zip Code:94558-3328
Mailing Address - Country:US
Mailing Address - Phone:310-702-2084
Mailing Address - Fax:
Practice Address - Street 1:3273 CLAREMONT WAY STE 100
Practice Address - Street 2:
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94558
Practice Address - Country:US
Practice Address - Phone:707-254-7117
Practice Address - Fax:707-265-6435
Is Sole Proprietor?:No
Enumeration Date:2012-12-03
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN56195207X00000X
390200000X
CAA128602207XX0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program