Provider Demographics
NPI:1376501411
Name:WONG, JASON MA (MPT)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:MA
Last Name:WONG
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 SORREL LN
Mailing Address - Street 2:
Mailing Address - City:SAN CARLOS
Mailing Address - State:CA
Mailing Address - Zip Code:94070-1530
Mailing Address - Country:US
Mailing Address - Phone:650-591-3976
Mailing Address - Fax:
Practice Address - Street 1:5050 EL CAMINO REAL
Practice Address - Street 2:SUITE 210
Practice Address - City:LOS ALTOS
Practice Address - State:CA
Practice Address - Zip Code:94022-1530
Practice Address - Country:US
Practice Address - Phone:650-559-0011
Practice Address - Fax:650-559-0012
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27604225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist