MEDICARE: JAE YOUN KIM FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	RN213977	GA
2	363LF0000X	Family Nurse Practitioner	95034282	CA

General Provider Information

NPI Number	:	1720519283
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAE YOUN KIM FNP-C

Provider Business Mailing Address
First Line	:	1375 BLOSSOM HILL RD STE 49
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95118-3806
Country	:	US
Telephone Number	:	408-645-7073
Fax Number	:	669-500-7491

Provider Business Practice Location Address
First Line	:	1375 BLOSSOM HILL RD STE 49
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95118-3806
Country	:	US
Telephone Number	:	408-645-7073
Fax Number	:	669-500-7491

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/25/2017
Last Update Date	:	12/02/2025

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