=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083258073
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JASUNG KIM PSYCHIATRIST CLINIC, APC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2019
-----------------------------------------------------
Last Update Date | 05/25/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 505 SHATTO PL STE 204
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90020-1777
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-797-5953
-----------------------------------------------------
Fax | 888-550-3121
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 505 SHATTO PL
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90020-1754
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-797-5953
-----------------------------------------------------
Fax | 888-550-3121
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. JASUNG KIM
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 213-797-5953
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------