Provider Demographics
NPI:1215338348
Name:KING, JAMES KEVIN (EDS)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:KEVIN
Last Name:KING
Suffix:
Gender:M
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:261 CAREN AVE
Mailing Address - Street 2:
Mailing Address - City:WORTHINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43085-2526
Mailing Address - Country:US
Mailing Address - Phone:614-507-5985
Mailing Address - Fax:
Practice Address - Street 1:261 CAREN AVE
Practice Address - Street 2:
Practice Address - City:WORTHINGTON
Practice Address - State:OH
Practice Address - Zip Code:43085-2526
Practice Address - Country:US
Practice Address - Phone:614-507-5985
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-08
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHWV1004354103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHWV1004354Medicaid