Provider Demographics
NPI:1629561667
Name:PARK, JASON CHAN HYUNG (PT, DPT, SCS)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:CHAN HYUNG
Last Name:PARK
Suffix:
Gender:M
Credentials:PT, DPT, SCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1506 VENICE BLVD APT 207
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291-5925
Mailing Address - Country:US
Mailing Address - Phone:310-701-9971
Mailing Address - Fax:
Practice Address - Street 1:2440 W CARSON ST
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90501-3146
Practice Address - Country:US
Practice Address - Phone:310-701-9971
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-13
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA422322251S0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Multi-Specialty