Provider Demographics
NPI:1952669715
Name:VONG, JENNIFER (DO)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:VONG
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6969 BROCKTON AVE STE A
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-3813
Mailing Address - Country:US
Mailing Address - Phone:951-530-8989
Mailing Address - Fax:951-530-8877
Practice Address - Street 1:6969 BROCKTON AVE STE A
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-3813
Practice Address - Country:US
Practice Address - Phone:951-530-8989
Practice Address - Fax:951-530-8877
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016025642207V00000X
CA20A15528207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty