MEDICARE: DR. JEOUNG P PARK PSYCHOLOGIST

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PSY29775	CA

General Provider Information

NPI Number	:	1578723805
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEOUNG P PARK PSYCHOLOGIST

Provider Business Mailing Address
First Line	:	4460 W SHAW AVE # 555
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93722-6210
Country	:	US
Telephone Number	:	559-492-6689
Fax Number	:

Provider Business Practice Location Address
First Line	:	1357 W SHAW AVE
Second Line	:	STE 104
City	:	FRESNO
State	:	CA
Zip	:	93711-3619
Country	:	US
Telephone Number	:	559-970-4812
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/10/2008
Last Update Date	:	09/10/2018

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