Provider Demographics
NPI:1235316761
Name:PARK, JYUNG KYUNG (LCSW)
Entity type:Individual
Prefix:MS
First Name:JYUNG KYUNG
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3727 W 6TH STREET
Mailing Address - Street 2:SUITE 411
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90020
Mailing Address - Country:US
Mailing Address - Phone:213-365-7400
Mailing Address - Fax:213-201-3993
Practice Address - Street 1:3727 W 6TH STREET
Practice Address - Street 2:SUITE 411
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90020
Practice Address - Country:US
Practice Address - Phone:213-365-7400
Practice Address - Fax:213-201-3993
Is Sole Proprietor?:No
Enumeration Date:2008-01-28
Last Update Date:2015-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225400000X
CALCSW286651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA001612200OtherMEDI-CAL