Healthcare Provider Details

I. General information

NPI: 1912891326
Provider Name (Legal Business Name): JAE UNG PARK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JAY PARK

II. Dates (important events)

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

III. Provider practice location address

14 FORDHAM RD
BOSTON MA
02134-3000
US

IV. Provider business mailing address

139 WASHINGTON ST APT 737
BOSTON MA
02135-4372
US

V. Phone/Fax

Practice location:
  • Phone: 617-782-6460
  • Fax:
Mailing address:
  • Phone: 617-952-3530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225A00000X
TaxonomyMusic Therapist
License Number17416
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: