MEDICARE: JESSICA KIM PA-C, D.C., L.AC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111NS0005X	Sports Physician Chiropractor	DC 32286	CA
2	171100000X	Acupuncturist	AC 14601	CA
3	363A00000X	Physician Assistant	55087	CA

General Provider Information

NPI Number	:	1285908673
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA KIM PA-C, D.C., L.AC

Provider Business Mailing Address
First Line	:	2100 PLAZA DEL AMO UNIT 112
Second Line	:
City	:	TORRANCE
State	:	CA
Zip	:	90501-3406
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1125 E 16TH ST
Second Line	:	SUITE 4
City	:	UPLAND
State	:	CA
Zip	:	91784-9179
Country	:	US
Telephone Number	:	909-297-3531
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/02/2012
Last Update Date	:	10/26/2017

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