Healthcare Provider Details

I. General information

NPI: 1992662407
Provider Name (Legal Business Name): JONATHAN KIM PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2026
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1211 W IMPERIAL HWY STE 210
BREA CA
92821-3733
US

IV. Provider business mailing address

1211 W IMPERIAL HWY STE 210
BREA CA
92821-3733
US

V. Phone/Fax

Practice location:
  • Phone: 323-970-2625
  • Fax:
Mailing address:
  • Phone: 323-970-2625
  • Fax: 310-496-6767

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95037573
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: