Provider Demographics
NPI:1740864370
Name:PARK, JEESOON
Entity type:Individual
Prefix:
First Name:JEESOON
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 1:12152 NAPOLI DR
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-2773
Mailing Address - Country:US
Mailing Address - Phone:310-402-3751
Mailing Address - Fax:
Practice Address - Street 1:13300 HAWTHORNE BLVD
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250-5805
Practice Address - Country:US
Practice Address - Phone:424-365-3031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-10
Last Update Date:2024-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA950286792084P0800X
CA532285163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty