Provider Demographics
NPI:1275418980
Name:KIM, JENNY
Entity type:Individual
Prefix:
First Name:JENNY
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4150 DEP BILL CANTRELL MEMORIAL RD STE 290
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040-3002
Mailing Address - Country:US
Mailing Address - Phone:404-446-0600
Mailing Address - Fax:404-446-0601
Practice Address - Street 1:4150 DEP BILL CANTRELL MEMORIAL RD STE 290
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-3002
Practice Address - Country:US
Practice Address - Phone:404-446-0600
Practice Address - Fax:404-446-0601
Is Sole Proprietor?:No
Enumeration Date:2025-08-11
Last Update Date:2025-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA13291363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical