Healthcare Provider Details

I. General information

NPI: 1053988741
Provider Name (Legal Business Name): JADE PARK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2021
Last Update Date: 09/12/2024
Certification Date: 09/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 4TH ST
ALEXANDRIA LA
71301-8411
US

IV. Provider business mailing address

301 4TH ST
ALEXANDRIA LA
71301-8411
US

V. Phone/Fax

Practice location:
  • Phone: 318-441-1041
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01093877A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: