Healthcare Provider Details

I. General information

NPI: 1285963694
Provider Name (Legal Business Name): JUDITH JUSTIN PARK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2009
Last Update Date: 12/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1870 CORDELL CT SUITE 101
EL CAJON CA
92020-0914
US

IV. Provider business mailing address

1870 CORDELL CT SUITE 101
EL CAJON CA
92020-0914
US

V. Phone/Fax

Practice location:
  • Phone: 619-448-9700
  • Fax: 619-448-9711
Mailing address:
  • Phone: 619-448-9700
  • Fax: 619-448-9711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMF 57669
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: