Healthcare Provider Details

I. General information

NPI: 1346077351
Provider Name (Legal Business Name): JAE EUN KIM FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2024
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3030 W OLYMPIC BLVD STE 206
LOS ANGELES CA
90006-6506
US

IV. Provider business mailing address

3030 W OLYMPIC BLVD STE 206
LOS ANGELES CA
90006-6506
US

V. Phone/Fax

Practice location:
  • Phone: 213-332-2666
  • Fax:
Mailing address:
  • Phone: 213-332-2666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95031733
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: