Provider Demographics
NPI:1689055030
Name:KIM, JENNIFER
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:932 N MARSHALL ST APT 1
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19123-1345
Mailing Address - Country:US
Mailing Address - Phone:302-632-3177
Mailing Address - Fax:
Practice Address - Street 1:240 GEIGER RD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19115-1008
Practice Address - Country:US
Practice Address - Phone:302-632-3177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-11
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI026745001223P0221X
390200000X
PADS0416411223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program