Provider Demographics
NPI:1558759795
Name:PARK-WAY, JENNIFER (PHD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:PARK-WAY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 N SAN MATEO DR
Mailing Address - Street 2:SUITE #3
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401-2493
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:415 N SAN MATEO DR
Practice Address - Street 2:SUITE #3
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-2493
Practice Address - Country:US
Practice Address - Phone:650-569-0120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-22
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22238103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist