Healthcare Provider Details

I. General information

NPI: 1316577620
Provider Name (Legal Business Name): JONATHAN JAME WONG PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2020
Last Update Date: 01/12/2026
Certification Date: 01/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 LOCH RAVEN BLVD
BALTIMORE MD
21218-2108
US

IV. Provider business mailing address

3021 CARLEE RUN CT
ELLICOTT CITY MD
21042-2158
US

V. Phone/Fax

Practice location:
  • Phone: 410-605-7000
  • Fax:
Mailing address:
  • Phone: 631-974-1688
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR269240
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number405708
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR269240
License Number StateMD
# 4
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number806394
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: