Healthcare Provider Details

I. General information

NPI: 1871056739
Provider Name (Legal Business Name): JACQUELINE ILJI KIM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2019
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BARNES JEWISH HOSPITAL PLZ
SAINT LOUIS MO
63110-1003
US

IV. Provider business mailing address

100 N KINGSHIGHWAY BLVD APT 2107
SAINT LOUIS MO
63108-1583
US

V. Phone/Fax

Practice location:
  • Phone: 314-747-9889
  • Fax: 314-361-4197
Mailing address:
  • Phone: 917-655-2299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2026024431
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: