Basic Information
| Provider Information | |||||||||
| NPI: | 1790748473 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | SHIN HAE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2050 PFINGSTEN RD STE 320 | ||||||||
| Address2: | |||||||||
| City: | GLENVIEW | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600261324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8479984170 | ||||||||
| FaxNumber: | 8479984165 | ||||||||
| Practice Location | |||||||||
| Address1: | 2050 PFINGSTEN RD STE 320 | ||||||||
| Address2: | |||||||||
| City: | GLENVIEW | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8479984170 | ||||||||
| FaxNumber: | 8479984165 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2006 | ||||||||
| LastUpdateDate: | 08/09/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0201X | 036103662 | IL | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Allergy/Immunology |
ID Information
| ID | Type | State | Issuer | Description | 036103662 | 05 | IL | MEDICAID |