Provider Demographics
NPI:1598468092
Name:WONG, JASON (RD, LDN)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:WONG
Suffix:
Gender:M
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 SOUTH DAMEN AVENUE
Mailing Address - Street 2:DAMEN 3547
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612
Mailing Address - Country:US
Mailing Address - Phone:312-752-5511
Mailing Address - Fax:
Practice Address - Street 1:820 S DAMEN AVE
Practice Address - Street 2:DAMEN 3547
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3728
Practice Address - Country:US
Practice Address - Phone:312-752-5511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-23
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL86065797133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered