Provider Demographics
NPI:1467499228
Name:PARK, JENNIFER Y (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:Y
Last Name:PARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 S FAIR OAKS AVE
Mailing Address - Street 2:SUITE 255
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-2613
Mailing Address - Country:US
Mailing Address - Phone:626-304-2626
Mailing Address - Fax:
Practice Address - Street 1:625 S FAIR OAKS AVE
Practice Address - Street 2:SUITE 255
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-2613
Practice Address - Country:US
Practice Address - Phone:626-304-2626
Practice Address - Fax:626-585-0695
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003004247207V00000X
CAA91570207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0101240Medicaid
CA00A91570Medicaid
CAGR0101241Medicaid
MO925680091Medicare ID - Type UnspecifiedSJH-MO
CAGR0101241Medicaid
CA00A91570Medicaid