Provider Demographics
NPI:1881843142
Name:WONG, JENNY SUH
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:SUH
Last Name:WONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6550 FANNIN ST
Mailing Address - Street 2:SUITE 1401
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-2717
Mailing Address - Country:US
Mailing Address - Phone:713-441-5200
Mailing Address - Fax:713-793-7428
Practice Address - Street 1:6550 FANNIN ST
Practice Address - Street 2:SUITE 1401
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2717
Practice Address - Country:US
Practice Address - Phone:713-441-5200
Practice Address - Fax:713-793-7428
Is Sole Proprietor?:No
Enumeration Date:2008-09-11
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002122363A00000X
NY013473-1363AS0400X
TXPA08414363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX323911303Medicaid
CT002122OtherCT LICENSE
TX323911304Medicaid
TX8583NPOtherBCBS
TX8765NYOtherBCBS
TX8765NYOtherBCBS
TX323911303Medicaid