Provider Demographics
NPI:1922424274
Name:PARK, JEFFERY S (LMFT 108456)
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:S
Last Name:PARK
Suffix:
Gender:M
Credentials:LMFT 108456
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4010 SAWTELLE BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-5408
Mailing Address - Country:US
Mailing Address - Phone:213-290-3870
Mailing Address - Fax:
Practice Address - Street 1:4010 SAWTELLE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-5408
Practice Address - Country:US
Practice Address - Phone:213-290-3870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-11
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF79146106H00000X
108456106H00000X
106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist