Provider Demographics
NPI:1821632431
Name:KIM, JINSE (PHD, LPC)
Entity Type:Individual
Prefix:
First Name:JINSE
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:PHD, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6538 CREEK RUN DR
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20121-3865
Mailing Address - Country:US
Mailing Address - Phone:703-531-9401
Mailing Address - Fax:
Practice Address - Street 1:14631 LEE HWY STE 313
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:VA
Practice Address - Zip Code:20121-5834
Practice Address - Country:US
Practice Address - Phone:703-650-9099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-06
Last Update Date:2023-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701008862101YP2500X
MDLC10007101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional