Provider Demographics
NPI:1740339076
Name:PARK, JI-HAE (LSW)
Entity type:Individual
Prefix:
First Name:JI-HAE
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 PARK CENTER DR
Mailing Address - Street 2:APT. #A909
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22302-1431
Mailing Address - Country:US
Mailing Address - Phone:703-379-1890
Mailing Address - Fax:
Practice Address - Street 1:6245 LEESBURG PIKE
Practice Address - Street 2:4TH FLOOR - OUTREACH
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22044-2106
Practice Address - Country:US
Practice Address - Phone:703-531-6283
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0903001428104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker