Healthcare Provider Details

I. General information

NPI: 1952093122
Provider Name (Legal Business Name): JESSICA PARK PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2023
Last Update Date: 05/24/2023
Certification Date: 05/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8008 WESTPARK DR
MC LEAN VA
22102-3109
US

IV. Provider business mailing address

5486 OWENS WOOD CT
CENTREVILLE VA
20120-6104
US

V. Phone/Fax

Practice location:
  • Phone: 844-549-0597
  • Fax:
Mailing address:
  • Phone: 571-432-8839
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number0202214173
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0202214173
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: