Provider Demographics
NPI:1366597254
Name:PERSONS, KATHRYN JANE (LCSW)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:JANE
Last Name:PERSONS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:911 IRONWOOD DR
Mailing Address - Street 2:
Mailing Address - City:YORKTOWN
Mailing Address - State:VA
Mailing Address - Zip Code:23693-5563
Mailing Address - Country:US
Mailing Address - Phone:774-788-1064
Mailing Address - Fax:
Practice Address - Street 1:825 DILIGENCE DR STE 206
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-4272
Practice Address - Country:US
Practice Address - Phone:757-310-6900
Practice Address - Fax:757-240-5936
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1078651041C0700X
VA09040080851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1898906Medicaid
MAP07340OtherBLUE CROSS
MA1898906Medicaid