Provider Demographics
NPI:1437278025
Name:PARK, JAKE J (DC)
Entity Type:Individual
Prefix:DR
First Name:JAKE
Middle Name:J
Last Name:PARK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:9005 CHEVROLET DR
Mailing Address - Street 2:SUITE 4
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-4009
Mailing Address - Country:US
Mailing Address - Phone:410-465-3221
Mailing Address - Fax:410-465-3514
Practice Address - Street 1:9005 CHEVROLET DR
Practice Address - Street 2:SUITE 4
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-4009
Practice Address - Country:US
Practice Address - Phone:410-465-3221
Practice Address - Fax:410-465-3514
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD02017111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor