Provider Demographics
NPI:1811286149
Name:KIM, JENNIFER LEE (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEE
Last Name:KIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 CORPORATE CENTER DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MORROW
Mailing Address - State:GA
Mailing Address - Zip Code:30260-4180
Mailing Address - Country:US
Mailing Address - Phone:770-968-8888
Mailing Address - Fax:770-960-2473
Practice Address - Street 1:1000 CORPORATE CENTER DR
Practice Address - Street 2:SUITE 100
Practice Address - City:MORROW
Practice Address - State:GA
Practice Address - Zip Code:30260-4180
Practice Address - Country:US
Practice Address - Phone:770-968-8888
Practice Address - Fax:770-960-2473
Is Sole Proprietor?:No
Enumeration Date:2011-04-07
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA074038207W00000X
SC38366207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
581787543OtherEYE CARE CENTERS MANAGEMENT, INC. D/B/A CLAYTON EYE CENTER
GA003181756AMedicaid