Provider Demographics
NPI:1750783437
Name:KIM, JEONG-A (JENNIE)
Entity type:Individual
Prefix:
First Name:JEONG-A (JENNIE)
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 1:3155 SW MOODY AVE APT 716
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-4735
Mailing Address - Country:US
Mailing Address - Phone:541-829-0626
Mailing Address - Fax:
Practice Address - Street 1:3155 SW MOODY AVE APT 716
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-4735
Practice Address - Country:US
Practice Address - Phone:541-829-0626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-24
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0014353183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist