Healthcare Provider Details

I. General information

NPI: 1487956322
Provider Name (Legal Business Name): JENNIFER Y. KIM MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2010
Last Update Date: 11/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 E 7TH ST STE M
UPLAND CA
91786-6701
US

IV. Provider business mailing address

360 E 7TH ST STE M
UPLAND CA
91786-6701
US

V. Phone/Fax

Practice location:
  • Phone: 909-608-0855
  • Fax:
Mailing address:
  • Phone: 909-608-0855
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA75250
License Number StateCA

VIII. Authorized Official

Name: DR. JENNIFER KIM
Title or Position: PHYSICIAN, CEO
Credential: M.D.
Phone: 909-608-0855