Provider Demographics
NPI:1336583137
Name:LO, JACQUELINE TIN WAI WONG
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:TIN WAI WONG
Last Name:LO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18802 48TH AVE
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11365-1243
Mailing Address - Country:US
Mailing Address - Phone:718-746-4976
Mailing Address - Fax:
Practice Address - Street 1:18802 48TH AVE
Practice Address - Street 2:
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11365-1243
Practice Address - Country:US
Practice Address - Phone:718-746-4976
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-23
Last Update Date:2013-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY519895111174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist