Healthcare Provider Details

I. General information

NPI: 1467245159
Provider Name (Legal Business Name): JAE YEUN KIM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2025
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 W 39TH AVE
SAN MATEO CA
94403-4364
US

IV. Provider business mailing address

2000 ALAMEDA DE LAS PULGAS STE 235
SAN MATEO CA
94403-1185
US

V. Phone/Fax

Practice location:
  • Phone: 650-573-2222
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number20461
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: