Provider Demographics
NPI:1255810008
Name:WONG, JADE (OTR/L, CHT, CLT)
Entity type:Individual
Prefix:
First Name:JADE
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:OTR/L, CHT, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2703 ROCKEFELLER LN APT 2
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90278-4299
Mailing Address - Country:US
Mailing Address - Phone:808-285-5090
Mailing Address - Fax:
Practice Address - Street 1:2703 ROCKEFELLER LN APT 2
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90278-4299
Practice Address - Country:US
Practice Address - Phone:808-285-5090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-13
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14398208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation