Basic Information
| Provider Information | |||||||||
| NPI: | 1316396906 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PARK | ||||||||
| FirstName: | JOANN | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1462 CEDARBROOK RD | ||||||||
| Address2: | |||||||||
| City: | WEST SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956915084 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2245775251 | ||||||||
| FaxNumber: | 9167340849 | ||||||||
| Practice Location | |||||||||
| Address1: | 2230 STOCKTON BLVD | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958171353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167342614 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2016 | ||||||||
| LastUpdateDate: | 09/28/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0804X | A151063 | CA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
No ID Information.