Healthcare Provider Details

I. General information

NPI: 1184336414
Provider Name (Legal Business Name): JENNIFER DENISE WONG PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2022
Last Update Date: 12/19/2022
Certification Date: 12/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 SAN PEDRO DR SE
ALBUQUERQUE NM
87108-5153
US

IV. Provider business mailing address

8003 PRINCESS JEANNE AVE NE
ALBUQUERQUE NM
87110-6019
US

V. Phone/Fax

Practice location:
  • Phone: 505-265-1711
  • Fax:
Mailing address:
  • Phone: 310-480-9573
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY-2022-0101
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: