Provider Demographics
NPI:1689340366
Name:PARK, JINEON
Entity Type:Individual
Prefix:
First Name:JINEON
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12741 DARBY BROOK CT STE 102
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-2406
Mailing Address - Country:US
Mailing Address - Phone:888-467-8241
Mailing Address - Fax:
Practice Address - Street 1:12741 DARBY BROOK CT STE 102
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-2406
Practice Address - Country:US
Practice Address - Phone:888-467-8241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-21
Last Update Date:2021-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician