Provider Demographics
NPI:1376165910
Name:KANG, JI YUN (PHD, LP)
Entity Type:Individual
Prefix:
First Name:JI YUN
Middle Name:
Last Name:KANG
Suffix:
Gender:F
Credentials:PHD, LP
Other - Prefix:
Other - First Name:JIYUN
Other - Middle Name:
Other - Last Name:KANG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD, LP
Mailing Address - Street 1:5 EVERGREEN CIR APT B
Mailing Address - Street 2:
Mailing Address - City:SAVOY
Mailing Address - State:IL
Mailing Address - Zip Code:61874-8717
Mailing Address - Country:US
Mailing Address - Phone:217-904-9556
Mailing Address - Fax:
Practice Address - Street 1:610 E JOHN ST RM 236
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-5717
Practice Address - Country:US
Practice Address - Phone:217-333-3704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-16
Last Update Date:2020-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY31197103T00000X
IL071.009777103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist