Provider Demographics
NPI:1912891326
Name:PARK, JAE UNG
Entity type:Individual
Prefix:
First Name:JAE UNG
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JAY
Other - Middle Name:
Other - Last Name:PARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:139 WASHINGTON ST APT 737
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-4372
Mailing Address - Country:US
Mailing Address - Phone:617-952-3530
Mailing Address - Fax:
Practice Address - Street 1:14 FORDHAM RD
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02134-3000
Practice Address - Country:US
Practice Address - Phone:617-782-6460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-09
Last Update Date:2025-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17416225A00000X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist