MEDICARE: MS. JACKIE WONG LCSW

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	1041C0700X	Clinical Social Worker	LCS 20579	CA

General Provider Information

NPI Number	:	1588034037
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JACKIE WONG LCSW

Provider Business Mailing Address
First Line	:	4108 ALAMEDA DE LAS PULGAS
Second Line	:
City	:	SAN MATEO
State	:	CA
Zip	:	94403-5053
Country	:	US
Telephone Number	:	415-215-8019
Fax Number	:

Provider Business Practice Location Address
First Line	:	4108 ALAMEDA DE LAS PULGAS
Second Line	:
City	:	SAN MATEO
State	:	CA
Zip	:	94403-5053
Country	:	US
Telephone Number	:	415-215-8019
Fax Number	:

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

Provider Enumeration Date	:	09/27/2015
Last Update Date	:	09/27/2015

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