Provider Demographics
NPI:1790435733
Name:PARK, JENNIFER ANN (RN)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:PARK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22026 20TH AVE SE STE 101
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98021-4449
Mailing Address - Country:US
Mailing Address - Phone:425-672-7293
Mailing Address - Fax:
Practice Address - Street 1:22026 20TH AVE SE STE 101
Practice Address - Street 2:
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98021-4449
Practice Address - Country:US
Practice Address - Phone:425-672-7293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-24
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60754129163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse