Provider Demographics
NPI:1780843177
Name:KIM, JANAE
Entity Type:Individual
Prefix:
First Name:JANAE
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 1:3190 OAKWOOD AVE.
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90004
Mailing Address - Country:US
Mailing Address - Phone:626-354-0528
Mailing Address - Fax:
Practice Address - Street 1:3190 OAKWOOD AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90004-1220
Practice Address - Country:US
Practice Address - Phone:213-252-2100
Practice Address - Fax:213-383-3146
Is Sole Proprietor?:No
Enumeration Date:2008-06-02
Last Update Date:2014-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF79690101YM0800X
174400000X
CA56772101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA9300Medicaid