Basic Information
| Provider Information | |||||||||
| NPI: | 1093727281 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DE JONG | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | JOY | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MA, LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4232 143RD ST | ||||||||
| Address2: | |||||||||
| City: | CRESTWOOD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604452600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087103696 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6006 159TH ST BLDG C | ||||||||
| Address2: | THE GENESIS THERAPY CENTER | ||||||||
| City: | OAK FOREST | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604522904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7085357320 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | IL | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.