Basic Information
| Provider Information | |||||||||
| NPI: | 1598314254 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | JENNIFER | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 285 BOULEVARD NE STE 610 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303124212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4046530039 | ||||||||
| FaxNumber: | 4046530159 | ||||||||
| Practice Location | |||||||||
| Address1: | 285 BOULEVARD NE STE 610 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303124212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4046530039 | ||||||||
| FaxNumber: | 4046530159 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2019 | ||||||||
| LastUpdateDate: | 08/10/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN240927 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.