Healthcare Provider Details

I. General information

NPI: 1740104538
Provider Name (Legal Business Name): JI YEON KIM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2026
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2625 ZANKER RD STE 201
SAN JOSE CA
95134-2130
US

IV. Provider business mailing address

19550 VALLCO PKWY UNIT 231
CUPERTINO CA
95014-7159
US

V. Phone/Fax

Practice location:
  • Phone: 408-468-0100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: