Provider Demographics
NPI:1831690783
Name:WONG, JEANNIE (LAC, DAOM)
Entity type:Individual
Prefix:
First Name:JEANNIE
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:LAC, DAOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2595 E WASHINGTON BLVD STE 108
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107-1409
Mailing Address - Country:US
Mailing Address - Phone:626-639-3887
Mailing Address - Fax:
Practice Address - Street 1:2595 E WASHINGTON BLVD STE 108
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91107-1409
Practice Address - Country:US
Practice Address - Phone:626-639-3887
Practice Address - Fax:626-639-3887
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-26
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC17768171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist