Healthcare Provider Details

I. General information

NPI: 1134582265
Provider Name (Legal Business Name): JESSAMINE JOY FAUSTINO-WONG MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JESSAMINE FAUSTINO MD

II. Dates (important events)

Enumeration Date: 04/05/2016
Last Update Date: 02/11/2022
Certification Date: 06/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 PINOLE VALLEY RD
PINOLE CA
94564-1384
US

IV. Provider business mailing address

1301 PINOLE VALLEY RD
PINOLE CA
94564-1384
US

V. Phone/Fax

Practice location:
  • Phone: 510-243-4200
  • Fax:
Mailing address:
  • Phone: 510-243-4200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA150475
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: