Provider Demographics
NPI:1245821669
Name:PARK, JERRICA (PA-C)
Entity type:Individual
Prefix:
First Name:JERRICA
Middle Name:
Last Name:PARK
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3630
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86003-3630
Mailing Address - Country:US
Mailing Address - Phone:928-522-9879
Mailing Address - Fax:
Practice Address - Street 1:1120 W UNIVERSITY AVE STE 101
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-2851
Practice Address - Country:US
Practice Address - Phone:928-522-1300
Practice Address - Fax:928-522-1301
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-28
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9452363A00000X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ157725Medicaid