Provider Demographics
NPI:1720338510
Name:PARK, JEONG AE (LAC, PHD)
Entity Type:Individual
Prefix:DR
First Name:JEONG AE
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:LAC, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8045 RAVENNA LN
Mailing Address - Street 2:
Mailing Address - City:STANTON
Mailing Address - State:CA
Mailing Address - Zip Code:90680-3388
Mailing Address - Country:US
Mailing Address - Phone:714-715-4223
Mailing Address - Fax:714-716-8314
Practice Address - Street 1:12235 BEACH BLVD STE 115A
Practice Address - Street 2:
Practice Address - City:STANTON
Practice Address - State:CA
Practice Address - Zip Code:90680-3942
Practice Address - Country:US
Practice Address - Phone:714-715-4223
Practice Address - Fax:714-716-8314
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-19
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC13960171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist