Provider Demographics
NPI:1326017708
Name:FONG, JEFFREY A
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:A
Last Name:FONG
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 1:9601 STEILACOOM BLVD SW
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98498-7213
Mailing Address - Country:US
Mailing Address - Phone:253-582-8900
Mailing Address - Fax:253-756-2879
Practice Address - Street 1:9601 STEILACOOM BLVD SW
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98498-7213
Practice Address - Country:US
Practice Address - Phone:253-582-8900
Practice Address - Fax:253-756-2879
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-16
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00002340103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP30051Medicare UPIN
WAAB21186Medicare PIN