Basic Information
| Provider Information | |||||||||
| NPI: | 1487197885 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PARK | ||||||||
| FirstName: | JESSICA | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 220 N MCKEMY AVE | ||||||||
| Address2: | |||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852262654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809611865 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7700 W ARROWHEAD TOWNE CTR | ||||||||
| Address2: | SUITE 1136 | ||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853088616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6239799830 | ||||||||
| FaxNumber: | 6024164657 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2016 | ||||||||
| LastUpdateDate: | 01/03/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 2153 | AZ | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.