Provider Demographics
NPI:1578723805
Name:PARK, JEOUNG P (PSYCHOLOGIST)
Entity Type:Individual
Prefix:DR
First Name:JEOUNG
Middle Name:P
Last Name:PARK
Suffix:
Gender:M
Credentials:PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4460 W SHAW AVE # 555
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93722-6210
Mailing Address - Country:US
Mailing Address - Phone:559-492-6689
Mailing Address - Fax:
Practice Address - Street 1:1357 W SHAW AVE
Practice Address - Street 2:STE 104
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-3619
Practice Address - Country:US
Practice Address - Phone:559-970-4812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-10
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY29775103TC0700X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical