Provider Demographics
NPI:1225658586
Name:PARK, JUYEON (MSW STUDENT)
Entity Type:Individual
Prefix:
First Name:JUYEON
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:MSW STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5011 N DEFIANCE ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98407-2131
Mailing Address - Country:US
Mailing Address - Phone:206-519-7311
Mailing Address - Fax:
Practice Address - Street 1:2136 M.L.K. JR WAY
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405
Practice Address - Country:US
Practice Address - Phone:253-285-0821
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-16
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOC61027012224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant