Healthcare Provider Details

I. General information

NPI: 1053798264
Provider Name (Legal Business Name): JENNIFER KIM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2015
Last Update Date: 09/09/2020
Certification Date: 09/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 KINGS HWY SURGERY
SHREVEPORT LA
71103-4228
US

IV. Provider business mailing address

8600 N STATE ROUTE 91
PEORIA IL
61615-9541
US

V. Phone/Fax

Practice location:
  • Phone: 318-675-2655
  • Fax:
Mailing address:
  • Phone: 309-691-4005
  • Fax: 309-691-6144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036153868
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: