Provider Demographics
NPI:1285257279
Name:GONG, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:GONG
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 1:14565 E ALAMEDA AVE APT 138
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80012-2612
Mailing Address - Country:US
Mailing Address - Phone:770-596-6827
Mailing Address - Fax:
Practice Address - Street 1:3960 RIVER POINT PKWY UNIT A
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:CO
Practice Address - Zip Code:80110-3315
Practice Address - Country:US
Practice Address - Phone:303-781-2340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-25
Last Update Date:2021-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.00204879122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program