Provider Demographics
NPI:1023199924
Name:PARK, JAE YOUNG (ACUPUNCTURIST)
Entity Type:Individual
Prefix:DR
First Name:JAE
Middle Name:YOUNG
Last Name:PARK
Suffix:
Gender:M
Credentials:ACUPUNCTURIST
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:300 HOSPITAL RD
Mailing Address - Street 2:INTERDISCIPLINARY PAIN MANAGEMENT CENTER
Mailing Address - City:FORT GORDON
Mailing Address - State:GA
Mailing Address - Zip Code:30905-5741
Mailing Address - Country:US
Mailing Address - Phone:706-787-8322
Mailing Address - Fax:706-787-0196
Practice Address - Street 1:300 W HOSPITAL RD BLDG 3006TH
Practice Address - Street 2:INTERDISCIPLINARY PAIN MANAGEMENT CENTER
Practice Address - City:FORT GORDON
Practice Address - State:GA
Practice Address - Zip Code:30905-5741
Practice Address - Country:US
Practice Address - Phone:706-787-0716
Practice Address - Fax:706-787-0196
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA11226171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist