MEDICARE: JESSICA WONGWARD D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	DR0059087	CO

General Provider Information

NPI Number	:	1477930873
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA WONGWARD D.O.

Provider Business Mailing Address
First Line	:	777 BANNOCK ST
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80204-4597
Country	:	US
Telephone Number	:	303-602-0000
Fax Number	:

Provider Business Practice Location Address
First Line	:	1339 S FEDERAL BLVD
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80219
Country	:	US
Telephone Number	:	303-602-0000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/05/2015
Last Update Date	:	07/12/2024

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