Healthcare Provider Details

I. General information

NPI: 1710357983
Provider Name (Legal Business Name): JESSICA PONG PHARM D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2015
Last Update Date: 09/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 9TH AVE
SEATTLE WA
98104-2420
US

IV. Provider business mailing address

14027 LAKE CITY WAY NE APT E609
SEATTLE WA
98125-3850
US

V. Phone/Fax

Practice location:
  • Phone: 206-744-4186
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License NumberPH60570580
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: