Provider Demographics
NPI:1184706996
Name:JAE PAK PC
Entity type:Organization
Organization Name:JAE PAK PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JAE
Authorized Official - Middle Name:H
Authorized Official - Last Name:PAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-982-1111
Mailing Address - Street 1:2160 FOUNTAIN DRIVE
Mailing Address - Street 2:200
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-6783
Mailing Address - Country:US
Mailing Address - Phone:770-982-1111
Mailing Address - Fax:770-982-7280
Practice Address - Street 1:2160 FOUNTAIN DRIVE
Practice Address - Street 2:200
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-6783
Practice Address - Country:US
Practice Address - Phone:770-982-1111
Practice Address - Fax:770-982-7280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2025-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0401852084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric PsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAF53884Medicare UPIN