Healthcare Provider Details

I. General information

NPI: 1093727281
Provider Name (Legal Business Name): KIMBERLY JOY DE JONG MA, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6006 159TH ST BLDG C THE GENESIS THERAPY CENTER
OAK FOREST IL
60452-2904
US

IV. Provider business mailing address

4232 143RD ST
CRESTWOOD IL
60445-2600
US

V. Phone/Fax

Practice location:
  • Phone: 708-535-7320
  • Fax:
Mailing address:
  • Phone: 708-710-3696
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: