Provider Demographics
NPI:1629622576
Name:WONG, JESSICA JOHANNA NALANI (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:JOHANNA NALANI
Last Name:WONG
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 13056
Mailing Address - Street 2:
Mailing Address - City:AIEA
Mailing Address - State:HI
Mailing Address - Zip Code:96701-8556
Mailing Address - Country:US
Mailing Address - Phone:808-207-0637
Mailing Address - Fax:
Practice Address - Street 1:98-1274 HOOHIKI PL APT B
Practice Address - Street 2:
Practice Address - City:PEARL CITY
Practice Address - State:HI
Practice Address - Zip Code:96782-3521
Practice Address - Country:US
Practice Address - Phone:808-207-0637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-29
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HILCSW-44501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI800221Medicaid