Healthcare Provider Details

I. General information

NPI: 1992351274
Provider Name (Legal Business Name): JYYEUN HONG KIM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2019
Last Update Date: 08/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3785 S PLAZA DR
SANTA ANA CA
92704-7463
US

IV. Provider business mailing address

21 ABETO
IRVINE CA
92620-1802
US

V. Phone/Fax

Practice location:
  • Phone: 714-828-2000
  • Fax:
Mailing address:
  • Phone: 949-705-8626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number114710
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: