=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528868759
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DEFINED KJ INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/17/2025
-----------------------------------------------------
Last Update Date | 03/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 935 LAKEVIEW PKWY UNIT 101, SUITE #9
-----------------------------------------------------
City | VERNON HILLS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60061
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-202-3249
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 288 MARSEILLES ST
-----------------------------------------------------
City | VERNON HILLS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60061-4148
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JIMMY NINH
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 414-202-3249
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------