Provider Demographics
NPI:1558516708
Name:PARK, JENNIFER YOON GAAHEE (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:YOON GAAHEE
Last Name:PARK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:YOON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:1802 RAINBOW TERRACE LN
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-1951
Mailing Address - Country:US
Mailing Address - Phone:323-566-4111
Mailing Address - Fax:
Practice Address - Street 1:11900 SOUTH ST
Practice Address - Street 2:
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90703-6847
Practice Address - Country:US
Practice Address - Phone:888-227-3312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-01
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18765363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA18765OtherCONSUMER AFFAIRS-CA