Provider Demographics
NPI:1487095501
Name:KIM, JACQUELINE HYO JU (PHD)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:HYO JU
Last Name:KIM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:HYO JU
Other - Middle Name:
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1141 S GARFIELD AVE STE 200
Practice Address - Street 2:
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91801-4714
Practice Address - Country:US
Practice Address - Phone:626-588-2825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-17
Last Update Date:2021-06-29
Deactivation Date:2021-05-28
Deactivation Code:
Reactivation Date:2021-06-22
Provider Licenses
StateLicense IDTaxonomies
CA32623103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist