Provider Demographics
NPI:1235620428
Name:PARK, JESSICA ERIN (RN)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:ERIN
Last Name:PARK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 ABIGAIL LN
Mailing Address - Street 2:
Mailing Address - City:PORT MATILDA
Mailing Address - State:PA
Mailing Address - Zip Code:16870-7153
Mailing Address - Country:US
Mailing Address - Phone:814-272-7713
Mailing Address - Fax:814-272-6507
Practice Address - Street 1:132 ABIGAIL LANE
Practice Address - Street 2:
Practice Address - City:PORT MATILDA
Practice Address - State:PA
Practice Address - Zip Code:16870-7153
Practice Address - Country:US
Practice Address - Phone:814-272-7713
Practice Address - Fax:814-272-6507
Is Sole Proprietor?:No
Enumeration Date:2018-05-23
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN525954L163WW0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WW0101XNursing Service ProvidersRegistered NurseWomen's Health Care, Ambulatory