Provider Demographics
NPI:1770394827
Name:KIM, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
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 1:7211 9TH ST
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90621-2770
Mailing Address - Country:US
Mailing Address - Phone:213-249-2759
Mailing Address - Fax:
Practice Address - Street 1:2500 REDHILL AVE STE 100
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-5518
Practice Address - Country:US
Practice Address - Phone:949-748-8571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-17
Last Update Date:2025-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26993225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics