Provider Demographics
NPI:1801510755
Name:KIM, JENNIFER SOOYOUNG (PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:SOOYOUNG
Last Name:KIM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23961 CALLE DE LA MAGDALENA STE 500
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-7622
Mailing Address - Country:US
Mailing Address - Phone:949-855-1101
Mailing Address - Fax:949-855-8710
Practice Address - Street 1:23961 CALLE DE LA MAGDALENA STE 500
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-7622
Practice Address - Country:US
Practice Address - Phone:949-855-1101
Practice Address - Fax:949-855-8710
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-03
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA63750363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant