Healthcare Provider Details

I. General information

NPI: 1053162578
Provider Name (Legal Business Name): JENNIFER WANG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2024
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W ARBOR DR # 851
SAN DIEGO CA
92103-1911
US

IV. Provider business mailing address

200 W ARBOR DR # 851
SAN DIEGO CA
92103-1911
US

V. Phone/Fax

Practice location:
  • Phone: 858-335-2661
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA205056
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: