Provider Demographics
NPI:1063402147
Name:PARK, JENNIFER M (MD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:M
Last Name:PARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:80 ROLLINGWOOD LN
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:MA
Mailing Address - Zip Code:01742-4302
Mailing Address - Country:US
Mailing Address - Phone:703-403-4204
Mailing Address - Fax:571-446-4015
Practice Address - Street 1:131 OLD ROAD TO 9 ACRE COR STE 620
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:MA
Practice Address - Zip Code:01742-4191
Practice Address - Country:US
Practice Address - Phone:703-403-4204
Practice Address - Fax:571-446-4015
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-28
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA2100492084P0800X
VA01012482102084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA210049OtherTUFTS HEALTH PLAN
H85800Medicare UPIN
MAA35436Medicare ID - Type Unspecified
MAJ26130OtherBCBS MA
MA2008343Medicaid