Provider Demographics
NPI:1790952042
Name:WONG, JESSICA L (DC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:WONG
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:L
Other - Last Name:CORKILL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:6474 NANCY RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-2248
Mailing Address - Country:US
Mailing Address - Phone:858-888-5550
Mailing Address - Fax:858-638-1476
Practice Address - Street 1:6474 NANCY RIDGE DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-2248
Practice Address - Country:US
Practice Address - Phone:858-888-5550
Practice Address - Fax:858-638-1476
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-14
Last Update Date:2012-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30866111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor