Healthcare Provider Details

I. General information

NPI: 1336883891
Provider Name (Legal Business Name): JENNIFER KIM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2022
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4502 MEDICAL DR
SAN ANTONIO TX
78229-4492
US

IV. Provider business mailing address

811 E ELMIRA ST UNIT 3
SAN ANTONIO TX
78212-2907
US

V. Phone/Fax

Practice location:
  • Phone: 210-358-4000
  • Fax: 210-358-4775
Mailing address:
  • Phone: 214-244-7932
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberV7750
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: