Provider Demographics
NPI:1104316546
Name:FONG, JARED
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:
Last Name:FONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7777 E FREEDOM RD
Mailing Address - Street 2:
Mailing Address - City:FRENCH CAMP
Mailing Address - State:CA
Mailing Address - Zip Code:95231-9694
Mailing Address - Country:US
Mailing Address - Phone:209-946-3400
Mailing Address - Fax:
Practice Address - Street 1:7777 E FREEDOM RD
Practice Address - Street 2:
Practice Address - City:FRENCH CAMP
Practice Address - State:CA
Practice Address - Zip Code:95231-9694
Practice Address - Country:US
Practice Address - Phone:209-946-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-10
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA179900208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation