Healthcare Provider Details

I. General information

NPI: 1699394593
Provider Name (Legal Business Name): JI YEON PAK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JANICE JIYEON PAK

II. Dates (important events)

Enumeration Date: 04/10/2020
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 GLENLAKE PKWY
SANDY SPRINGS GA
30328-3473
US

IV. Provider business mailing address

925 SENECA ST MAIL SOP: H8-GME
SEATTLE WA
98101
US

V. Phone/Fax

Practice location:
  • Phone: 404-365-0966
  • Fax:
Mailing address:
  • Phone: 206-583-6079
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number113531
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: