Healthcare Provider Details

I. General information

NPI: 1376178731
Provider Name (Legal Business Name): JASON PARK OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2020
Last Update Date: 03/06/2020
Certification Date: 03/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 GRAND AVE
ENGLEWOOD NJ
07631-4934
US

IV. Provider business mailing address

142 RELDYES AVE
LEONIA NJ
07605-1231
US

V. Phone/Fax

Practice location:
  • Phone: 201-541-1111
  • Fax:
Mailing address:
  • Phone: 551-404-7370
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number46TR00782700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: