Provider Demographics
NPI:1861020992
Name:WANG, JESSICA YOUNG (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:YOUNG
Last Name:WANG
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2160 LAGO MADERO
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91914-2093
Mailing Address - Country:US
Mailing Address - Phone:619-948-5433
Mailing Address - Fax:
Practice Address - Street 1:2160 LAGO MADERO
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91914-2093
Practice Address - Country:US
Practice Address - Phone:619-948-5433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-01
Last Update Date:2020-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP26605235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist