Healthcare Provider Details

I. General information

NPI: 1689735284
Provider Name (Legal Business Name): JORGE WONG PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 02/14/2022
Certification Date: 02/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 MOORPARK AVE SUITE 300
SAN JOSE CA
95128-2631
US

IV. Provider business mailing address

46 RACE ST
SAN JOSE CA
95126-3130
US

V. Phone/Fax

Practice location:
  • Phone: 408-975-2730
  • Fax: 408-975-2745
Mailing address:
  • Phone: 408-961-9818
  • Fax: 408-961-9856

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY21180
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: