Healthcare Provider Details

I. General information

NPI: 1760751861
Provider Name (Legal Business Name): JACOB PARKS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2011
Last Update Date: 12/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11335 SUNSET HILLS RD
RESTON VA
20190-5205
US

IV. Provider business mailing address

PO BOX 1048
GREAT FALLS VA
22066-9048
US

V. Phone/Fax

Practice location:
  • Phone: 703-348-7857
  • Fax: 703-444-4308
Mailing address:
  • Phone: 703-348-7857
  • Fax: 703-444-4308

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code224Y00000X
TaxonomyClinical Exercise Physiologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: