Provider Demographics
NPI:1689735284
Name:WONG, JORGE (PHD)
Entity Type:Individual
Prefix:DR
First Name:JORGE
Middle Name:
Last Name:WONG
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 RACE ST
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95126-3130
Mailing Address - Country:US
Mailing Address - Phone:408-961-9818
Mailing Address - Fax:408-961-9856
Practice Address - Street 1:2400 MOORPARK AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-2631
Practice Address - Country:US
Practice Address - Phone:408-975-2730
Practice Address - Fax:408-975-2745
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY21180103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY21180OtherCINICAL PSYCHOLOGY LICENS