Basic Information
| Provider Information | |||||||||
| NPI: | 1902118086 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 7150 E CAMELBACK RD STE 105 | ||||||||
| Address2: | |||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852511240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022184072 | ||||||||
| FaxNumber: | 6022184076 | ||||||||
| Practice Location | |||||||||
| Address1: | 7150 E CAMELBACK RD STE 105 | ||||||||
| Address2: | |||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852511240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022184072 | ||||||||
| FaxNumber: | 6022184076 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2010 | ||||||||
| LastUpdateDate: | 11/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 11/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD165658 | OR | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 47260 | AZ | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 022959 | 05 | OR | MEDICAID | 096511 | 05 | OR | MEDICAID |