Provider Demographics
NPI:1114645876
Name:PARK, JENNA (MA, NCC, LPC, ATR)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:MA, NCC, LPC, ATR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 LAKESIDE DR E
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND LAKES
Mailing Address - State:NJ
Mailing Address - Zip Code:07422-2049
Mailing Address - Country:US
Mailing Address - Phone:973-303-8613
Mailing Address - Fax:
Practice Address - Street 1:27 FORESTDALE RD
Practice Address - Street 2:
Practice Address - City:KINNELON
Practice Address - State:NJ
Practice Address - Zip Code:07405-2558
Practice Address - Country:US
Practice Address - Phone:973-303-8613
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-18
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00871800101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health