=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447589692
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEANNE KIM PSY.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/17/2009
-----------------------------------------------------
Last Update Date | 09/20/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21053 DEVONSHIRE ST SUITE 101
-----------------------------------------------------
City | CHATSWORTH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91311-2364
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-726-5326
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21053 DEVONSHIRE ST SUITE 101
-----------------------------------------------------
City | CHATSWORTH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91311-2364
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TA0700X
-----------------------------------------------------
Taxonomy Name | Adult Development & Aging Psychologist
-----------------------------------------------------
License Number | PSY22888
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY22888
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 103G00000X
-----------------------------------------------------
Taxonomy Name | Clinical Neuropsychologist
-----------------------------------------------------
License Number | PSY22888
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 103TC2200X
-----------------------------------------------------
Taxonomy Name | Clinical Child & Adolescent Psychologist
-----------------------------------------------------
License Number | PSY 22888
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------