Provider Demographics
NPI:1679979728
Name:PARK, MARY JARET (PT, DPT)
Entity type:Individual
Prefix:
First Name:MARY JARET
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5200 GREYSTONE SUMMIT DR APT 415
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31909-7546
Mailing Address - Country:US
Mailing Address - Phone:931-809-0354
Mailing Address - Fax:
Practice Address - Street 1:5131 WARM SPRINGS RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31909-4196
Practice Address - Country:US
Practice Address - Phone:931-809-0354
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-17
Last Update Date:2014-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT011766225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist