Provider Demographics
NPI:1235737545
Name:GONG, JANINE L (DPT)
Entity Type:Individual
Prefix:
First Name:JANINE
Middle Name:L
Last Name:GONG
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 KENMAR WAY
Mailing Address - Street 2:
Mailing Address - City:BURLINGAME
Mailing Address - State:CA
Mailing Address - Zip Code:94010-6034
Mailing Address - Country:US
Mailing Address - Phone:650-291-9227
Mailing Address - Fax:
Practice Address - Street 1:400 PARNASSUS AVE RM A-68
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94143-2202
Practice Address - Country:US
Practice Address - Phone:650-291-9227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-09
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA298712225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA298712OtherPT BOARD OF CALIFORNIA