Provider Demographics
NPI:1700116704
Name:PARK, JEA YOUNG (L, AC)
Entity Type:Individual
Prefix:MR
First Name:JEA YOUNG
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:L, AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4449 CASA GRANDE CIR APT 423
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:CA
Mailing Address - Zip Code:90630-2589
Mailing Address - Country:US
Mailing Address - Phone:213-820-3812
Mailing Address - Fax:
Practice Address - Street 1:3100 E IMPERIAL HWY # J11
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-3232
Practice Address - Country:US
Practice Address - Phone:310-609-2820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-13
Last Update Date:2010-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC10228171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist