Provider Demographics
NPI:1255544359
Name:ANG, JESSY AWITEN
Entity type:Individual
Prefix:MR
First Name:JESSY
Middle Name:AWITEN
Last Name:ANG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2411 S 19TH ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-2954
Mailing Address - Country:US
Mailing Address - Phone:253-627-6606
Mailing Address - Fax:253-572-4291
Practice Address - Street 1:2411 S 19TH ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-2954
Practice Address - Country:US
Practice Address - Phone:253-627-6606
Practice Address - Fax:253-572-4291
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA180962084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1548908Medicaid
WAA08306Medicare UPIN
WA8853161Medicare ID - Type Unspecified