Provider Demographics
NPI:1477794436
Name:WONG, JONATHAN (DC)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:WONG
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19767 SW 72ND AVE
Mailing Address - Street 2:STE 103
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-8354
Mailing Address - Country:US
Mailing Address - Phone:503-620-6480
Mailing Address - Fax:
Practice Address - Street 1:19767 SW 72ND AVE
Practice Address - Street 2:STE 103
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-8354
Practice Address - Country:US
Practice Address - Phone:503-620-6480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-20
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3811111NI0900X, 111NS0005X, 111NX0100X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NI0900XChiropractic ProvidersChiropractorInternist
No111NS0005XChiropractic ProvidersChiropractorSports Physician
No111NX0100XChiropractic ProvidersChiropractorOccupational Health