Provider Demographics
NPI:1194290429
Name:JONG, JENNIFER B
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:B
Last Name:JONG
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 1:583 E FOOTHILL BLVD STE 8
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4076
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2227 S SHORE CTR
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-8029
Practice Address - Country:US
Practice Address - Phone:510-863-9004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-13
Last Update Date:2018-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA79696183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist