Healthcare Provider Details

I. General information

NPI: 1861553018
Provider Name (Legal Business Name): JEANIE KIM P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 UCLA MEDICAL PLZ
LOS ANGELES CA
90095-6985
US

IV. Provider business mailing address

1560 S SALTAIR AVE APT 104
LOS ANGELES CA
90025-2608
US

V. Phone/Fax

Practice location:
  • Phone: 310-794-1323
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number24370
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: