Provider Demographics
NPI:1508835786
Name:WONG, JENNIFER LYNN (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:WONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 E CHAPMAN AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92869-3204
Mailing Address - Country:US
Mailing Address - Phone:714-628-3230
Mailing Address - Fax:714-633-7175
Practice Address - Street 1:1310 W STEWART DR
Practice Address - Street 2:SUITE 603
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3854
Practice Address - Country:US
Practice Address - Phone:714-633-3145
Practice Address - Fax:714-633-0145
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-17
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG63866207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G638660Medicaid
CAF02761Medicare UPIN
CAG63866Medicare ID - Type Unspecified