Provider Demographics
NPI:1942776133
Name:PARK, JINA (LCSW)
Entity type:Individual
Prefix:
First Name:JINA
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 1:79 MONROE AVE
Mailing Address - Street 2:
Mailing Address - City:CRESSKILL
Mailing Address - State:NJ
Mailing Address - Zip Code:07626-1438
Mailing Address - Country:US
Mailing Address - Phone:562-708-6558
Mailing Address - Fax:
Practice Address - Street 1:121 NEWARK AVE STE 410
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07302-5873
Practice Address - Country:US
Practice Address - Phone:201-677-2232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-16
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY098215-11041C0700X
NJ44SC062808001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical