Healthcare Provider Details

I. General information

NPI: 1245821669
Provider Name (Legal Business Name): JERRICA PARK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/28/2021
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 W UNIVERSITY AVE STE 101
FLAGSTAFF AZ
86001-2851
US

IV. Provider business mailing address

PO BOX 3630
FLAGSTAFF AZ
86003-3630
US

V. Phone/Fax

Practice location:
  • Phone: 928-522-1300
  • Fax: 928-522-1301
Mailing address:
  • Phone: 928-522-9879
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9452
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number65593
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: