Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TS0200X | School Psychologist | 0813000764 | VA |
NPI | 1023514312 |
---|---|
Provider Name | Jennie Song |
First Address | Fairfax, VA 22031-4511 |
Second Address | Fairfax, VA 22031-4511 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/04/2018 |
Last Update Date | 04/04/2018 |