Provider Demographics
NPI:1053547851
Name:VILLASENOR-PARK, JENNIFER (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:VILLASENOR-PARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:VILLASENOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3400 SPRUCE ST
Mailing Address - Street 2:2 MALONEY BLDG
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-4238
Mailing Address - Country:US
Mailing Address - Phone:215-662-2737
Mailing Address - Fax:
Practice Address - Street 1:3400 SPRUCE ST
Practice Address - Street 2:2 MALONEY
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4238
Practice Address - Country:US
Practice Address - Phone:215-662-2737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-08
Last Update Date:2014-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD450451207N00000X
PAMT198034207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology