Provider Demographics
NPI:1295703023
Name:FONG, JENNIFER LYNN (OD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:LYNN
Last Name:FONG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1689 ARDEN WAY
Mailing Address - Street 2:#1091
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95815-4030
Mailing Address - Country:US
Mailing Address - Phone:916-929-5909
Mailing Address - Fax:916-929-8202
Practice Address - Street 1:1689 ARDEN WAY
Practice Address - Street 2:#1091
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95815-4030
Practice Address - Country:US
Practice Address - Phone:916-929-5909
Practice Address - Fax:916-929-8202
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12293T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU98070Medicare UPIN
CASD0122930Medicare ID - Type Unspecified