Provider Demographics
NPI:1437293461
Name:PARK, JEAN KIM
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:KIM
Last Name:PARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4050 GLENCOE AVE
Mailing Address - Street 2:#221
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-5608
Mailing Address - Country:US
Mailing Address - Phone:310-677-7808
Mailing Address - Fax:310-846-2139
Practice Address - Street 1:111 N LA BREA AVE
Practice Address - Street 2:SUITE 700
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-1752
Practice Address - Country:US
Practice Address - Phone:310-677-7808
Practice Address - Fax:310-846-2139
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health