Provider Demographics
NPI:1730750720
Name:KIM, JENNIE YANGDUK
Entity type:Individual
Prefix:MS
First Name:JENNIE
Middle Name:YANGDUK
Last Name:KIM
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:RHEA
Other - Middle Name:Y
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6333 TELEGRAPH AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-1359
Mailing Address - Country:US
Mailing Address - Phone:510-923-1099
Mailing Address - Fax:
Practice Address - Street 1:6333 TELEGRAPH AVE STE 102
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-1359
Practice Address - Country:US
Practice Address - Phone:510-923-1099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-09
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program