Provider Demographics
NPI:1619514098
Name:JUNG, KENIA MARISOL (LCMHCA)
Entity Type:Individual
Prefix:MS
First Name:KENIA
Middle Name:MARISOL
Last Name:JUNG
Suffix:
Gender:F
Credentials:LCMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:907 GRETNA GREEN DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28217-6412
Mailing Address - Country:US
Mailing Address - Phone:704-340-1098
Mailing Address - Fax:704-936-0122
Practice Address - Street 1:3700 LATROBE DR STE 5L
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1387
Practice Address - Country:US
Practice Address - Phone:704-340-1098
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-05
Last Update Date:2022-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA15389101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health