Provider Demographics
NPI:1225286875
Name:WONG, JENNIFER ROSES (OD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:ROSES
Last Name:WONG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 E WASHINGTON ST
Mailing Address - Street 2:SUITE 606
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60602-1708
Mailing Address - Country:US
Mailing Address - Phone:312-444-1111
Mailing Address - Fax:312-444-1953
Practice Address - Street 1:25 E WASHINGTON ST
Practice Address - Street 2:SUITE 606
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-1708
Practice Address - Country:US
Practice Address - Phone:312-444-1111
Practice Address - Fax:312-444-1953
Is Sole Proprietor?:No
Enumeration Date:2008-09-08
Last Update Date:2009-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003473A152W00000X
IL046-0101777152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046-0101777OtherILLINOIS LICENSE NUMBER