Healthcare Provider Details

I. General information

NPI: 1427392760
Provider Name (Legal Business Name): JENNIFER ALANE PARK LCSW-C, LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/26/2012
Last Update Date: 12/02/2021
Certification Date: 12/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 WOOD HILL RD
ROCKVILLE MD
20850-8724
US

IV. Provider business mailing address

200 WOOD HILL RD
ROCKVILLE MD
20850-8724
US

V. Phone/Fax

Practice location:
  • Phone: 301-838-4200
  • Fax:
Mailing address:
  • Phone: 301-838-4200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC50079244
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number17943
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: