Provider Demographics
NPI:1093316440
Name:PARK, JASON
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9600 VETERANS DR
Mailing Address - Street 2:BLDG 200, A-120-NFS, #F127
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98493
Mailing Address - Country:US
Mailing Address - Phone:253-583-2372
Mailing Address - Fax:
Practice Address - Street 1:9600 VETERANS DR
Practice Address - Street 2:BLDG 200, A-120-NFS, #F127
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98493
Practice Address - Country:US
Practice Address - Phone:253-583-2372
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered