Provider Demographics
NPI:1154526168
Name:WONG, JENNIFER JIMENEZ
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:JIMENEZ
Last Name:WONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 W 25TH AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94403-2208
Mailing Address - Country:US
Mailing Address - Phone:415-593-1212
Mailing Address - Fax:
Practice Address - Street 1:126 W 25TH AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94403-2208
Practice Address - Country:US
Practice Address - Phone:650-286-2090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2015-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 52281390200000X
CALMFT 50996106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program