Healthcare Provider Details

I. General information

NPI: 1790435733
Provider Name (Legal Business Name): JENNIFER ANN PARK RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2022
Last Update Date: 03/24/2022
Certification Date: 03/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22026 20TH AVE SE STE 101
BOTHELL WA
98021-4449
US

IV. Provider business mailing address

22026 20TH AVE SE STE 101
BOTHELL WA
98021-4449
US

V. Phone/Fax

Practice location:
  • Phone: 425-672-7293
  • Fax:
Mailing address:
  • Phone: 425-672-7293
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN60754129
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: