Healthcare Provider Details

I. General information

NPI: 1063627131
Provider Name (Legal Business Name): JANE Y WONG LPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 JOSE FIGUERES AVE
SAN JOSE CA
95116-2022
US

IV. Provider business mailing address

101 JOSE FIGUERES AVE
SAN JOSE CA
95116-2022
US

V. Phone/Fax

Practice location:
  • Phone: 408-347-3120
  • Fax: 408-347-3121
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License NumberPT24575
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: