Provider Demographics
NPI:1093849978
Name:NAMKOONG, JENNIFER Y (LPC, LCDC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:Y
Last Name:NAMKOONG
Suffix:
Gender:F
Credentials:LPC, LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12764 COLBORNE DR
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75033-6500
Mailing Address - Country:US
Mailing Address - Phone:425-435-6180
Mailing Address - Fax:
Practice Address - Street 1:3550 PARKWOOD BLVD STE 201A
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75034-2048
Practice Address - Country:US
Practice Address - Phone:425-435-6180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14122101YA0400X
TX78423101YP2500X
IL17253101YA0400X
IL180004177101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04932190OtherBLUE CROSS BLUE SHIELD
TX1093849978OtherNPI