Provider Demographics
NPI:1194363598
Name:WONG, JASON SOONG-JEE
Entity Type:Individual
Prefix:
First Name:JASON SOONG-JEE
Middle Name:
Last Name:WONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:948 EMBARCADERO DEL NORTE STE 102
Mailing Address - Street 2:
Mailing Address - City:ISLA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:93117-5106
Mailing Address - Country:US
Mailing Address - Phone:805-699-6668
Mailing Address - Fax:
Practice Address - Street 1:948 EMBARCADERO DEL NORTE STE 102
Practice Address - Street 2:
Practice Address - City:ISLA VISTA
Practice Address - State:CA
Practice Address - Zip Code:93117-5106
Practice Address - Country:US
Practice Address - Phone:805-699-6668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-16
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA32402103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program