Provider Demographics
NPI:1245663228
Name:KIM, JESSICA Y (DO)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:Y
Last Name:KIM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26732 CROWN VALLEY PKWY STE 571
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-7305
Mailing Address - Country:US
Mailing Address - Phone:949-200-7008
Mailing Address - Fax:
Practice Address - Street 1:26732 CROWN VALLEY PKWY STE 571
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-7305
Practice Address - Country:US
Practice Address - Phone:949-200-7008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-14
Last Update Date:2020-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLUO3501207R00000X
CA20A17031207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine