Provider Demographics
NPI:1699016667
Name:PARKS, JONATHAN HUGH
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:HUGH
Last Name:PARKS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27111 167TH PL SE
Mailing Address - Street 2:SUITE 105-210
Mailing Address - City:COVINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98042-7337
Mailing Address - Country:US
Mailing Address - Phone:206-954-5008
Mailing Address - Fax:
Practice Address - Street 1:27111 167TH PL SE
Practice Address - Street 2:SUITE 105-210
Practice Address - City:COVINGTON
Practice Address - State:WA
Practice Address - Zip Code:98042-7337
Practice Address - Country:US
Practice Address - Phone:206-954-5008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-14
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60335670172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker