Provider Demographics
NPI:1306226352
Name:WONG, JESSICA KAREN (MD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:KAREN
Last Name:WONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3509 N BROAD ST
Mailing Address - Street 2:SUITE 226
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19140-4105
Mailing Address - Country:US
Mailing Address - Phone:215-707-6400
Mailing Address - Fax:
Practice Address - Street 1:333 COTTMAN AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19111-2434
Practice Address - Country:US
Practice Address - Phone:215-728-2581
Practice Address - Fax:215-214-4038
Is Sole Proprietor?:No
Enumeration Date:2015-06-04
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PAMD4675872085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program