Provider Demographics
NPI:1619098316
Name:KIM, JIN AH RENEE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:JIN AH
Middle Name:RENEE
Last Name:KIM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19737
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97280
Mailing Address - Country:US
Mailing Address - Phone:971-808-8226
Mailing Address - Fax:
Practice Address - Street 1:12655 SW CENTER ST
Practice Address - Street 2:SUITE # 470
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-1600
Practice Address - Country:US
Practice Address - Phone:971-808-8226
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker