Provider Demographics
NPI:1760751861
Name:PARKS, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
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:PO BOX 1048
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:VA
Mailing Address - Zip Code:22066-9048
Mailing Address - Country:US
Mailing Address - Phone:703-348-7857
Mailing Address - Fax:703-444-4308
Practice Address - Street 1:11335 SUNSET HILLS RD
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-5205
Practice Address - Country:US
Practice Address - Phone:703-348-7857
Practice Address - Fax:703-444-4308
Is Sole Proprietor?:No
Enumeration Date:2011-12-19
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No133N00000XDietary & Nutritional Service ProvidersNutritionist
No224Y00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersClinical Exercise Physiologist