Provider Demographics
NPI:1770239386
Name:PARK, JEY (OTD, OTR/L)
Entity Type:Individual
Prefix:
First Name:JEY
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 GILLESPIE DR
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75010-6314
Mailing Address - Country:US
Mailing Address - Phone:469-955-9592
Mailing Address - Fax:
Practice Address - Street 1:1761 INTERNATIONAL PKWY STE 135
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75081-1864
Practice Address - Country:US
Practice Address - Phone:972-845-7875
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-23
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX467298225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist