Provider Demographics
NPI:1134582265
Name:FAUSTINO-WONG, JESSAMINE JOY (MD)
Entity type:Individual
Prefix:
First Name:JESSAMINE
Middle Name:JOY
Last Name:FAUSTINO-WONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JESSAMINE
Other - Middle Name:
Other - Last Name:FAUSTINO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1301 PINOLE VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:PINOLE
Mailing Address - State:CA
Mailing Address - Zip Code:94564-1384
Mailing Address - Country:US
Mailing Address - Phone:510-243-4200
Mailing Address - Fax:
Practice Address - Street 1:1301 PINOLE VALLEY RD
Practice Address - Street 2:
Practice Address - City:PINOLE
Practice Address - State:CA
Practice Address - Zip Code:94564-1384
Practice Address - Country:US
Practice Address - Phone:510-243-4200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-05
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA150475208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty