Provider Demographics
NPI:1205581352
Name:FONG, JAQUELINE (LMT)
Entity type:Individual
Prefix:
First Name:JAQUELINE
Middle Name:
Last Name:FONG
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10769 N FRANK LLOYD WRIGHT BLVD STE A110
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85259-2688
Mailing Address - Country:US
Mailing Address - Phone:602-405-8182
Mailing Address - Fax:
Practice Address - Street 1:10769 N FRANK LLOYD WRIGHT BLVD STE A110
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85259-2688
Practice Address - Country:US
Practice Address - Phone:602-405-8182
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-17
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-09340172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist