Provider Demographics
NPI:1386339091
Name:FONG, JASETTE MARIAN MANACSA (RN, APRN, MSN)
Entity type:Individual
Prefix:
First Name:JASETTE MARIAN
Middle Name:MANACSA
Last Name:FONG
Suffix:
Gender:F
Credentials:RN, APRN, MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1118 CAMINO CANTERA
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91913-3451
Mailing Address - Country:US
Mailing Address - Phone:619-548-0886
Mailing Address - Fax:
Practice Address - Street 1:34800 BOB WILSON DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-1098
Practice Address - Country:US
Practice Address - Phone:619-532-7049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-07
Last Update Date:2023-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA753824163WP0200X
CA4666364SP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPediatrics
No163WP0200XNursing Service ProvidersRegistered NursePediatrics