Individual
JENNIFER PARK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
4545 E CHANDLER BLVD STE 104, PHOENIX, AZ 85048
(480) 728-4400
(480) 222-3422
Mailing address
3030 N CENTRAL AVE STE 1001, PHOENIX, AZ 85012-2716
(602) 406-4786
(916) 636-4358
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
52982
AZ
207Q00000X
Family Medicine Physician
R74065
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
R74065
TRAINING PERMIT
AZ
Enumeration date
06/24/2013
Last updated
07/16/2019
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