Healthcare Provider Details

I. General information

NPI: 1699627570
Provider Name (Legal Business Name): JAEMIN PARK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2026
Last Update Date: 03/11/2026
Certification Date: 03/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10273 YELLOW CIRCLE DR
MINNETONKA MN
55343-9144
US

IV. Provider business mailing address

7016 47TH ST N
SAINT PAUL MN
55128-2640
US

V. Phone/Fax

Practice location:
  • Phone: 952-215-3753
  • Fax: 952-401-9805
Mailing address:
  • Phone: 507-351-1022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: