Provider Demographics
NPI:1861050718
Name:PARK, JEASUE JOSIE
Entity type:Individual
Prefix:DR
First Name:JEASUE
Middle Name:JOSIE
Last Name:PARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 BANK ST APT 106L
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10606-1982
Mailing Address - Country:US
Mailing Address - Phone:352-283-1929
Mailing Address - Fax:
Practice Address - Street 1:1775 GRAND CONCOURSE FL 6
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10453-8202
Practice Address - Country:US
Practice Address - Phone:718-590-1800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-04
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program