Provider Demographics
NPI:1053167510
Name:CHA, JEANJOO
Entity type:Individual
Prefix:
First Name:JEANJOO
Middle Name:
Last Name:CHA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JEANNIE
Other - Middle Name:
Other - Last Name:CHA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:6571 GRANGE LN UNIT 404
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22315-5861
Mailing Address - Country:US
Mailing Address - Phone:240-444-9317
Mailing Address - Fax:
Practice Address - Street 1:12020 SUNRISE VALLEY DR STE 100
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20191-3429
Practice Address - Country:US
Practice Address - Phone:240-444-9317
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-25
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0904016075101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health