Provider Demographics
NPI:1588218523
Name:CHONG, JENNIEFER
Entity Type:Individual
Prefix:
First Name:JENNIEFER
Middle Name:
Last Name:CHONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13500 LOS ANGELES ST
Mailing Address - Street 2:
Mailing Address - City:BALDWIN PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91706-2250
Mailing Address - Country:US
Mailing Address - Phone:626-216-6472
Mailing Address - Fax:
Practice Address - Street 1:210 W SAN BERNARDINO RD
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-1515
Practice Address - Country:US
Practice Address - Phone:626-938-7650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-29
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95018865363L00000X
CA776381163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse