Provider Demographics
NPI:1689147787
Name:KIM, JAMIE JAKYUN (LAC)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:JAKYUN
Last Name:KIM
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1942 AVENIDA DEL OSSA
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92833-1856
Mailing Address - Country:US
Mailing Address - Phone:714-422-8461
Mailing Address - Fax:
Practice Address - Street 1:2050 W CHAPMAN AVE STE 102
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-2648
Practice Address - Country:US
Practice Address - Phone:714-512-1978
Practice Address - Fax:714-948-8243
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-10
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC18310171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist