Healthcare Provider Details

I. General information

NPI: 1164547865
Provider Name (Legal Business Name): JESSIE JEAN PARK LPC-MH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5421 W 41ST ST
SIOUX FALLS SD
57106-1300
US

IV. Provider business mailing address

5421 W 41ST ST
SIOUX FALLS SD
57106-1300
US

V. Phone/Fax

Practice location:
  • Phone: 605-421-8749
  • Fax:
Mailing address:
  • Phone: 605-421-8749
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPCMH30853
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: