Provider Demographics
NPI:1285109504
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 1:320 WARD AVE STE 205
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96814-4017
Mailing Address - Country:US
Mailing Address - Phone:808-840-0556
Mailing Address - Fax:
Practice Address - Street 1:320 WARD AVE STE 205
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-4017
Practice Address - Country:US
Practice Address - Phone:808-840-0556
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-12
Last Update Date:2018-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIACU1249171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist