Provider Demographics
NPI:1730332966
Name:KIM, JACKYE (DC)
Entity type:Individual
Prefix:DR
First Name:JACKYE
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7305 HANCOCK VILLAGE DR # 118
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23832-2771
Mailing Address - Country:US
Mailing Address - Phone:804-399-0002
Mailing Address - Fax:
Practice Address - Street 1:15521 MIDLOTHIAN TPKE STE 402
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23113-7313
Practice Address - Country:US
Practice Address - Phone:804-399-0002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-31
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104556626111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor