Provider Demographics
NPI:1417374554
Name:VONG, JACK
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:VONG
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 1:360 KIELY BLVD.
Mailing Address - Street 2:SUITE #215
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95129
Mailing Address - Country:US
Mailing Address - Phone:408-260-8292
Mailing Address - Fax:
Practice Address - Street 1:360 KIELY BLVD.
Practice Address - Street 2:SUITE #215
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95129
Practice Address - Country:US
Practice Address - Phone:408-260-8292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-26
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28757111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor