Healthcare Provider Details

I. General information

NPI: 1780006221
Provider Name (Legal Business Name): JINAH KIM PAK LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2014
Last Update Date: 12/12/2019
Certification Date: 12/12/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11050 ARTESIA BLVD STE F
CERRITOS CA
90703-2542
US

IV. Provider business mailing address

11050 ARTESIA BLVD STE F
CERRITOS CA
90703-2542
US

V. Phone/Fax

Practice location:
  • Phone: 562-860-8838
  • Fax: 213-383-3146
Mailing address:
  • Phone: 562-860-8838
  • Fax: 213-383-3146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number36711
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberASW36711
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number81188
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: