Provider Demographics
NPI:1427765403
Name:WONG, JING-SHAN GERONIMO
Entity type:Individual
Prefix:
First Name:JING-SHAN
Middle Name:GERONIMO
Last Name:WONG
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 1:21042 E 60TH AVE # 100
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80019-2262
Mailing Address - Country:US
Mailing Address - Phone:720-238-4508
Mailing Address - Fax:
Practice Address - Street 1:3760 S TEMPE WAY # 100
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80018-4561
Practice Address - Country:US
Practice Address - Phone:720-545-0768
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-31
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO171372853106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician