Provider Demographics
NPI:1710202635
Name:PARKS, JESSICA JANEA (LMP)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:JANEA
Last Name:PARKS
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15232 SE 272ND ST
Mailing Address - Street 2:#10
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98042-4240
Mailing Address - Country:US
Mailing Address - Phone:206-455-3434
Mailing Address - Fax:253-631-4786
Practice Address - Street 1:15220 SE 272ND ST
Practice Address - Street 2:SUITE D
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98042-4241
Practice Address - Country:US
Practice Address - Phone:253-631-7933
Practice Address - Fax:253-631-4786
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-03
Last Update Date:2010-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60137544172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker