Provider Demographics
NPI:1033664727
Name:JENNIFER PARK, PSYCHOLOGIST
Entity Type:Organization
Organization Name:JENNIFER PARK, PSYCHOLOGIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:M
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:408-426-5725
Mailing Address - Street 1:160 LINFIELD DR
Mailing Address - Street 2:
Mailing Address - City:MENLO PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94025-3741
Mailing Address - Country:US
Mailing Address - Phone:909-973-4463
Mailing Address - Fax:
Practice Address - Street 1:900 WELCH RD
Practice Address - Street 2:SUITE 400
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94304-1805
Practice Address - Country:US
Practice Address - Phone:408-426-5725
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-23
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY27972103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty