Provider Demographics
NPI:1215098116
Name:HENAO, JAIME JESUS (CSAC)
Entity type:Individual
Prefix:
First Name:JAIME
Middle Name:JESUS
Last Name:HENAO
Suffix:
Gender:M
Credentials:CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5940 COVE LANDING RD
Mailing Address - Street 2:
Mailing Address - City:BURKE
Mailing Address - State:VA
Mailing Address - Zip Code:22015-4790
Mailing Address - Country:US
Mailing Address - Phone:703-250-8766
Mailing Address - Fax:
Practice Address - Street 1:720 N SAINT ASAPH ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-1912
Practice Address - Country:US
Practice Address - Phone:703-838-4455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0710101709101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)