Healthcare Provider Details

I. General information

NPI: 1457600884
Provider Name (Legal Business Name): JENNIFER WILEY KIM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER MICHELLE WILEY

II. Dates (important events)

Enumeration Date: 08/30/2012
Last Update Date: 08/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 SULLIVAN AVE
DALY CITY CA
94015-2200
US

IV. Provider business mailing address

86 GARDEN ST
SAN FRANCISCO CA
94115-3422
US

V. Phone/Fax

Practice location:
  • Phone: 650-991-6763
  • Fax:
Mailing address:
  • Phone: 415-531-4778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225500000X
TaxonomyRespiratory/Developmental/Rehabilitative Specialist/Technologist
License Number12866
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: