Provider Demographics
NPI:1346303856
Name:WONG, JENNIFER ANN (OD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
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 1:155 OAKLANE DR
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48306-3425
Mailing Address - Country:US
Mailing Address - Phone:248-608-0493
Mailing Address - Fax:
Practice Address - Street 1:28825 RYAN RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48092-4128
Practice Address - Country:US
Practice Address - Phone:586-573-0470
Practice Address - Fax:586-573-0648
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003737152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation