Provider Demographics
NPI:1154799245
Name:PARK, JIN (ND, LAC)
Entity type:Individual
Prefix:DR
First Name:JIN
Middle Name:
Last Name:PARK
Suffix:
Gender:M
Credentials:ND, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1935 SHERMER RD
Mailing Address - Street 2:SUITE 140
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-5384
Mailing Address - Country:US
Mailing Address - Phone:847-559-3200
Mailing Address - Fax:
Practice Address - Street 1:1935 SHERMER RD
Practice Address - Street 2:SUITE 140
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-5384
Practice Address - Country:US
Practice Address - Phone:847-559-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-08
Last Update Date:2015-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198.000439171100000X
OR1121175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No175F00000XOther Service ProvidersNaturopath