MEDICARE: JACQUELINE GORT WONG

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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1558877498
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE GORT WONG

Provider Business Mailing Address
First Line	:	1715 W 56TH TER
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33012-2002
Country	:	US
Telephone Number	:	786-399-7751
Fax Number	:

Provider Business Practice Location Address
First Line	:	1715 W 56TH TER
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33012-2002
Country	:	US
Telephone Number	:	786-399-7751
Fax Number	:

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

Provider Enumeration Date	:	12/14/2017
Last Update Date	:	12/14/2017

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Directions to “ JACQUELINE GORT WONG ” Practice Location

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