Provider Demographics
NPI:1487197885
Name:PARK, JESSICA (OD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:220 N MCKEMY AVE
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85226-2654
Mailing Address - Country:US
Mailing Address - Phone:480-961-1865
Mailing Address - Fax:
Practice Address - Street 1:7700 W ARROWHEAD TOWNE CTR
Practice Address - Street 2:SUITE 1136
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-8616
Practice Address - Country:US
Practice Address - Phone:623-979-9830
Practice Address - Fax:602-416-4657
Is Sole Proprietor?:No
Enumeration Date:2016-12-02
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2153152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist