Healthcare Provider Details

I. General information

NPI: 1295365849
Provider Name (Legal Business Name): JAESUNG PARK DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2020
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42 BROADWAY STE 1219
NEW YORK NY
10004-3834
US

IV. Provider business mailing address

1077 RIVER RD APT 1008
EDGEWATER NJ
07020-1357
US

V. Phone/Fax

Practice location:
  • Phone: 929-412-2654
  • Fax:
Mailing address:
  • Phone: 475-988-7695
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number38MC00767600
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number013393
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: