Provider Demographics
NPI:1770960999
Name:KIM, JENNIFER (LMFT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10302
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92838-6302
Mailing Address - Country:US
Mailing Address - Phone:714-745-5584
Mailing Address - Fax:
Practice Address - Street 1:19712 MACARTHUR BLVD STE 110
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92612-2407
Practice Address - Country:US
Practice Address - Phone:714-745-5584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-27
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA105051106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program