Provider Demographics
NPI:1437901113
Name:KIM, JIYOUNG WITTEMORE
Entity type:Individual
Prefix:
First Name:JIYOUNG
Middle Name:WITTEMORE
Last Name:KIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 SHADOW OAKS
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-4096
Mailing Address - Country:US
Mailing Address - Phone:626-344-4891
Mailing Address - Fax:
Practice Address - Street 1:18837 BROOKHURST ST STE 102
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-7301
Practice Address - Country:US
Practice Address - Phone:562-314-9890
Practice Address - Fax:714-699-1536
Is Sole Proprietor?:No
Enumeration Date:2024-04-04
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT144043106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist