Provider Demographics
NPI:1730817842
Name:KIM, JIN SUK
Entity type:Individual
Prefix:
First Name:JIN
Middle Name:SUK
Last Name:KIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7716 LAFAYETTE FOREST DR APT 31
Mailing Address - Street 2:
Mailing Address - City:ANNANDALE
Mailing Address - State:VA
Mailing Address - Zip Code:22003-6347
Mailing Address - Country:US
Mailing Address - Phone:571-212-2984
Mailing Address - Fax:
Practice Address - Street 1:430 E SHIRLEY AVE
Practice Address - Street 2:
Practice Address - City:WARRENTON
Practice Address - State:VA
Practice Address - Zip Code:20186-3725
Practice Address - Country:US
Practice Address - Phone:540-422-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-08
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0607570103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool