Provider Demographics
NPI:1669097572
Name:PARK, JISUN
Entity type:Individual
Prefix:
First Name:JISUN
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 NE 95TH ST APT A307
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98115-2056
Mailing Address - Country:US
Mailing Address - Phone:202-714-2893
Mailing Address - Fax:
Practice Address - Street 1:747 BROADWAY
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98122-4379
Practice Address - Country:US
Practice Address - Phone:202-714-2893
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-16
Last Update Date:2020-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA86064132133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered