Provider Demographics
NPI:1457600884
Name:KIM, JENNIFER WILEY
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:WILEY
Last Name:KIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:MICHELLE
Other - Last Name:WILEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:86 GARDEN ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94115-3422
Mailing Address - Country:US
Mailing Address - Phone:415-531-4778
Mailing Address - Fax:
Practice Address - Street 1:1900 SULLIVAN AVE
Practice Address - Street 2:
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94015-2200
Practice Address - Country:US
Practice Address - Phone:650-991-6763
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-30
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12866225500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225500000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/Technologist