Healthcare Provider Details

I. General information

NPI: 1053238535
Provider Name (Legal Business Name): JONATHAN PAK
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2026
Last Update Date: 07/03/2026
Certification Date: 07/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 SANTA MONICA BLVD STE 100W
SANTA MONICA CA
90404-2176
US

IV. Provider business mailing address

3585 S VERMONT AVE
LOS ANGELES CA
90007-5244
US

V. Phone/Fax

Practice location:
  • Phone: 310-496-7555
  • Fax:
Mailing address:
  • Phone: 657-386-6015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number51133
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: