Healthcare Provider Details

I. General information

NPI: 1104011931
Provider Name (Legal Business Name): MISS JEANINE PARKS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2007
Last Update Date: 06/06/2025
Certification Date: 06/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6250 N MILLBROOK AVE
FRESNO CA
93710-5620
US

IV. Provider business mailing address

4928 E CLINTON WAY STE 108
FRESNO CA
93727-1526
US

V. Phone/Fax

Practice location:
  • Phone: 559-431-7874
  • Fax:
Mailing address:
  • Phone: 559-252-2804
  • Fax: 559-252-2804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: