MEDICARE: JAEMIN PARK

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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1699627570
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAEMIN PARK

Provider Business Mailing Address
First Line	:	4610 ATLAS PL
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55129-4429
Country	:	US
Telephone Number	:	507-351-1022
Fax Number	:

Provider Business Practice Location Address
First Line	:	1011 MEADOWLANDS DR
Second Line	:
City	:	WHITE BEAR LAKE
State	:	MN
Zip	:	55127-2339
Country	:	US
Telephone Number	:	507-351-1022
Fax Number	:

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

Provider Enumeration Date	:	02/12/2026
Last Update Date	:	02/12/2026

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Directions to “ JAEMIN PARK ” Practice Location

Language	Start Address	Practice Location

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