Provider Demographics
NPI:1700097524
Name:KIM, JUA GRACE (MFTI)
Entity Type:Individual
Prefix:MISS
First Name:JUA
Middle Name:GRACE
Last Name:KIM
Suffix:
Gender:F
Credentials:MFTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24898 SANITARIUM DR
Mailing Address - Street 2:#299
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92350-0001
Mailing Address - Country:US
Mailing Address - Phone:213-925-5939
Mailing Address - Fax:
Practice Address - Street 1:6180 RIVERSIDE DR
Practice Address - Street 2:SUITE H
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-4536
Practice Address - Country:US
Practice Address - Phone:909-590-5355
Practice Address - Fax:909-590-5333
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE3975OtherEMPLOYEE ID