Provider Demographics
NPI:1033530910
Name:PARK, JAE
Entity type:Individual
Prefix:
First Name:JAE
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MARLBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:07746-1439
Mailing Address - Country:US
Mailing Address - Phone:732-431-2155
Mailing Address - Fax:
Practice Address - Street 1:17 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MARLBORO
Practice Address - State:NJ
Practice Address - Zip Code:07746-1439
Practice Address - Country:US
Practice Address - Phone:732-431-2155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-19
Last Update Date:2013-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01528600225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist