Provider Demographics
NPI:1497203657
Name:JIN, BRIAN
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:JIN
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 1:20 YORK ST
Mailing Address - Street 2:SOCIAL WORK EP10-635
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510-3220
Mailing Address - Country:US
Mailing Address - Phone:203-200-2632
Mailing Address - Fax:203-688-2395
Practice Address - Street 1:20 YORK ST
Practice Address - Street 2:SOCIAL WORK EP10-635
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3220
Practice Address - Country:US
Practice Address - Phone:203-200-2632
Practice Address - Fax:203-688-2395
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-16
Last Update Date:2016-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT88731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical